Nokea
The nurse has an order to administer 2 oz of lactulose (Cephulac) to a client who has cirrhosis. How many milliliters of lactulose should the nurse administer?
Correct Answer: 60 mL
Rationale: 2 oz = 60 mL (1 oz = 30 mL). Thus, the nurse should administer 60 mL of lactulose.
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A client with Parkinson's disease asks the nurse to explain to his nephew "what the doctor said the pallidotomy would do." The nurse's best response includes stating that the main goal for the client after pallidotomy is improved:
- A. Functional ability.
- B. Emotional stress.
- C. Alertness.
- D. Appetite.
Correct Answer: A
Rationale: Pallidotomy aims to improve functional ability by reducing symptoms like tremors and rigidity. Emotional stress, alertness, and appetite are not primary targets of this procedure.
A priority goal for the hospitalized client who 2 days earlier had a total laryngectomy with creation of a new tracheostomy would be to:
- A. Decrease secretions.
- B. Instruct the client in caring for the tracheostomy.
- C. Relieve anxiety related to the tracheostomy.
- D. Maintain a patent airway.
Correct Answer: D
Rationale: Maintaining a patent airway is the priority goal post-laryngectomy with a new tracheostomy to ensure adequate oxygenation and prevent respiratory distress.
A client with a hemorrhagic stroke is slightly agitated, heart rate is 118, respirations are 22, bilateral rhonchi are auscultated, SpO2 is 94%, blood pressure is 144/88, and oral secretions are noted. What order of interventions should the nurse follow when suctioning the client to prevent increased intracranial pressure (ICP) and maintain adequate cerebral perfusion?
- A. Suction the airway.
- B. Hyperoxygenate.
- C. Suction the mouth.
- D. Provide sedation.
Correct Answer: B,D,A,C
Rationale: The correct order is: 1) Hyperoxygenate to prevent hypoxia (B); 2) Provide sedation to reduce agitation and ICP spikes (D); 3) Suction the airway to clear secretions (A); 4) Suction the mouth to remove residual secretions (C). This sequence minimizes ICP increases and ensures oxygenation.
A nurse is palpating a female client's breast while assessing for breast disease. In the illustration below, indicate the area of the breast in which tumors are most commonly found.
Correct Answer:
Rationale: Most breast tumors are found in the upper outer quadrant of the breast, as this area contains the most glandular tissue.
Which dietary modification is appropriate for a client with calcium oxalate stones?
- A. Increase dairy intake.
- B. Limit spinach consumption.
- C. Reduce fluid intake.
- D. Eat more red meat.
Correct Answer: B
Rationale: Spinach is high in oxalates, which contribute to calcium oxalate stone formation.