Nokea
The nurse interprets which of the following as an early sign of acute respiratory distress syndrome (ARDS) in a client at risk?
- A. Elevated carbon dioxide level.
- B. Hypoxia not responsive to oxygen therapy.
- C. Metabolic acidosis.
- D. Severe, unexplained electrolyte imbalance.
Correct Answer: B
Rationale: Hypoxia unresponsive to oxygen therapy is an early ARDS sign due to impaired gas exchange. Elevated CO2, metabolic acidosis, and electrolyte imbalances occur later or are unrelated.
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A middle-aged man collapses in the emergency department waiting room. The triage nurse should first:
- A. Gently shake the victim and ask him to state his name.
- B. Perform the chin-tilt to open the victim's airway.
- C. Feel for any air movement from the victim's nose or mouth.
- D. Watch the victim's chest for respirations.
Correct Answer: A
Rationale: The first step in assessing an unresponsive patient is to check for responsiveness by gently shaking and calling out to the victim, per AHA guidelines, to determine if CPR or other interventions are needed.
The nurse should be especially alert for signs and symptoms of digoxin toxicity if serum levels indicate that the client has a:
- A. Low sodium level.
- B. High glucose level.
- C. High calcium level.
- D. Low potassium level.
Correct Answer: D
Rationale: Low potassium (hypokalemia) increases the risk of digoxin toxicity by enhancing digoxin's binding to cardiac cells, leading to arrhythmias.
A client is to be discharged with a prescription for lactulose (Cephulac). The nurse teaches the client and the client's spouse how to administer this medication. Which of the following statements would indicate that the client has understood the information?
- A. I'll take it with Maalox.'
- B. I'll mix it with apple juice.'
- C. I'll take it with a laxative.'
- D. I'll mix the crushed tablets in some gelatin.'
Correct Answer: B
Rationale: Mixing lactulose with apple juice (B) improves palatability. Maalox (A) is unrelated, additional laxatives (C) are unnecessary, and lactulose is a liquid, not a tablet (D).
The nurse is caring for a client with herpes simplex virus who is experiencing an outbreak. Which medication does the nurse anticipate that the primary healthcare provider (PHCP) will prescribe?
- A. metronidazole
- B. valacyclovir
- C. imiquimod
- D. fluconazole
Correct Answer: B
Rationale: Valacyclovir is an antiviral medication used to treat herpes simplex virus (HSV) outbreaks. Choice A (metronidazole) is for bacterial/parasitic infections, Choice C (imiquimod) is for genital warts, and Choice D (fluconazole) is for fungal infections.
The nurse is monitoring a client who received ketamine for anesthesia induction. Which side effect should the nurse prioritize?
- A. Hypotension.
- B. Respiratory depression.
- C. Vivid dreams or hallucinations.
- D. Bradycardia.
Correct Answer: C
Rationale: Ketamine can cause vivid dreams or hallucinations, which may distress the client during recovery. Monitoring and reassuring the client are critical to manage this psychological side effect.