Nokea
The nasogastric tube of a post-op gastrectomy client has stopped draining greenish liquid. The nurse should
- A. Irrigate it as ordered with distilled water
- B. Irrigate it as ordered with normal saline
- C. Check for kinking or obstruction
- D. Withdraw the tube several inches and reposition it
Correct Answer: B
Rationale: Irrigate it as ordered with normal saline. Nasogastric tubes are only irrigated with normal saline to maintain patency.
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The nurse is teaching a client with a new diagnosis of hypothyroidism about levothyroxine (Synthroid). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this medication in the morning.
- B. I should report chest pain to my doctor.
- C. I should avoid taking this with calcium supplements.
- D. I should stop this medication if I feel better.
Correct Answer: D
Rationale: Stopping levothyroxine when feeling better is incorrect, as hypothyroidism requires lifelong replacement therapy to maintain euthyroid status. Options A, B, and C are correct: morning dosing minimizes insomnia, chest pain may indicate overdose, and calcium supplements interfere with absorption.
A client taking phenelzine (Nardil) eating another client's lunch, then complaining of headache, nausea, rapid heartbeat, and vomiting.
The nurse anticipates administering which of the following medication?
- A. Buspirone (Buspar).
- B. Fluoxetine (Prozac).
- C. Prochlorperazine (Compazine).
- D. Nifedipine (Procardia).
Correct Answer: D
Rationale: Strategy: Think about the action of each medication. (1) antianxiety; side effects include light-headedness, confusion, hypotension, palpitations (2) SSRI antidepressant; side effects include palpitation, bradycardia, nausea and vomiting (3) antiemetic; side effects include drowsiness, orthostatic hypotension (4) correct-antihypertensive; client experiencing hypertensive crisis due to ingesting tyramine; side effects include dizziness, headache, nervousness
A client has a Swan-Ganz catheter in place. The nurse understands that this is intended to measure
- A. right heart function
- B. left heart function
- C. renal tubule function
- D. carotid artery function
Correct Answer: B
Rationale: left heart function. The Swan-Ganz catheter is placed in the pulmonary artery to obtain information about the left side of the heart. It can provide hemodynamic information such as intracardiac pressure readings and oxygen saturation data, and even transvenous pacing. Information about left ventricular function is important because it directly affects tissue perfusion. Right-sided heart function is assessed through the evaluation of the central venous pressure (CVP).
A woman is in active labor with her first child when her membranes rupture. She voices a concern to the nurse that she is afraid of having a 'dry labor.' Which of the following responses by the nurse would be MOST appropriate?
- A. The amniotic fluid provides only minimal lubrication for the labor process.
- B. The amniotic sac may impede the progress of labor and is often ruptured artificially.
- C. Labor is only slightly more difficult with early rupture of the amniotic sac.
- D. Because there is limited amniotic fluid, additional fluids will be supplied.
Correct Answer: B
Rationale: Rupture of membranes can facilitate labor by removing the sac, which may impede progress, addressing the client’s 'dry labor' concern. Options A, C, and D are incorrect: amniotic fluid has multiple roles, labor difficulty is not significantly increased, and no fluids are added.
An adult is taking digoxin and furosemide. Which laboratory value is of greatest concern to the nurse?
- A. Serum digoxin of 1.2 ng/mL
- B. Serum K+ of 3.0 mEq/L
- C. BUN of 12 mg/dL
- D. Serum Mg of 1.6 mEq/L
Correct Answer: B
Rationale: Furosemide, a diuretic, can cause hypokalemia (low potassium), increasing the risk of digoxin toxicity. A serum K+ of 3.0 mEq/L is below normal (3.5-5.0 mEq/L), posing a significant risk. The digoxin level is therapeutic (0.5-2.0 ng/mL), and BUN and Mg are within normal ranges.