Nokea
The nurse has rounded on all the assigned clients. While rounding, several health care providers have written orders on the nurse's clients. Which order would be the priority for the nurse to address?
- A. furosemide (Lasix) 80 mg IV push STAT for a client with fluid overload
- B. a new insulin sliding scale for a client with a glucose level of 242
- C. perform a dressing change on a client with a stage 2 diabetic foot ulcer
- D. discharge a client who was admitted for removal of an abdominal abscess
Correct Answer: A
Rationale: STAT orders for furosemide address acute fluid overload, a potentially life-threatening condition, making it the priority over insulin, dressing changes, or discharge.
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The physician orders an MRI of the spine with infusion for an adult female. Which of the following findings in the client's history should the nurse report to the physician?
- A. allergy to shellfish
- B. congestive heart failure (CHF)
- C. chronic cystitis
- D. metformin administered daily
Correct Answer: A
Rationale: Shellfish allergy may indicate iodine sensitivity, a concern for MRI contrast, requiring physician evaluation to prevent allergic reactions.
A client with a fractured hip is being taught correct use of the walker. The nurse is aware that the correct use of the walker is achieved if the:
- A. Palms rest lightly on the handles
- B. Elbows are flexed 0°
- C. Client walks to the front of the walker
- D. Client carries the walker
Correct Answer: A
Rationale: Palms resting lightly on the handles ensures proper weight distribution and stability.
The nurse is caring for a client with leukemia who has received the drug (daunorubicin) Cerubidine. Which of the following common side effects would cause the most concern?
- A. Nausea
- B. Vomiting
- C. Cardiotoxicity
- D. Alopecia
Correct Answer: C
Rationale: Daunorubicin is known for cardiotoxicity, which can lead to heart failure and is life-threatening, making it the most concerning side effect. Nausea, vomiting, and alopecia are common but less severe.
The nurse is assessing a client following a coronary artery bypass graft (CABG). The nurse should give priority to reporting:
- A. Chest drainage of 150 mL in the past hour
- B. Confusion and restlessness
- C. Pallor and coolness of skin
- D. Urinary output of 40 mL per hour
Correct Answer: B
Rationale: Confusion and restlessness may indicate cerebral hypoxia or other serious complications post-CABG, requiring immediate reporting.
The nurse is preparing to administer insulin to a client with type 1 diabetes mellitus. The client is to receive 10 units of regular insulin and 20 units of NPH insulin. Which of the following actions by the nurse is correct?
- A. Draw up the NPH insulin first, then the regular insulin in the same syringe.
- B. Administer the regular insulin in one syringe and the NPH in another.
- C. Mix the regular insulin with the NPH insulin in a vial before drawing it up.
- D. Administer the regular insulin 30 minutes after the NPH insulin.
Correct Answer: A
Rationale: regular insulin is drawn up first, followed by NPH, to prevent contamination of the regular insulin with NPH