Nokea
The nurse is administering an antacid to a client with gastroesophageal reflux disease. Which statement best describes the scientific rationale for administering this medication?
- A. This medication will suppress gastric acid secretion.
- B. This medication will decrease the gastric pH.
- C. This medication will coat the stomach lining.
- D. This medication interferes with prostaglandin production.
Correct Answer: C
Rationale: Antacids neutralize acid and coat the stomach, relieving GERD symptoms. Acid suppression, pH decrease, or prostaglandins are unrelated.
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A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first?
- A. Ask client to cough sputum into container
- B. Have the client take several deep breaths
- C. Provide an appropriate specimen container
- D. Assist with oral hygiene
Correct Answer: D
Rationale: Assist with oral hygiene. Obtain a specimen early in the morning after mouth care. The other responses follow this first action: the client should take several deep breaths then cough into the appropriate sterile container to obtain the AFB specimen of the sputum.
A client is receiving dexamethasone (Decadron) therapy. What should the nurse plan to monitor in this client?
- A. Urine output every 4 hours
- B. Blood glucose levels every 12 hours
- C. Neurological signs every 2 hours
- D. Oxygen saturation every 8 hours
Correct Answer: B
Rationale: The drug Decadron increases gluconeogenesis. This may lead to hyperglycemia. Therefore the blood sugar level and acetone production must be monitored.
A woman who is receiving cancer chemotherapy exhibits all of the following. Which is most indicative of bone marrow depression?
- A. Alopecia
- B. Petechiae
- C. Stomatitis
- D. Constipation
Correct Answer: B
Rationale: Petechiae indicate low platelets, a sign of bone marrow depression, a common chemotherapy side effect.
The health care provider has written 'Morphine sulfate 2 mgs IV every 3-4 hours prn for pain' on the chart of a child weighing 22 lb. (10 kg). What is the nurse's initial action?
- A. Check with the pharmacist
- B. Hold the medication and contact the provider
- C. Administer the prescribed dose as ordered
- D. Give the dose every 6-8 hours
Correct Answer: B
Rationale: Hold the medication and contact the provider. The usual pediatric dose of morphine is 0.1 mg/kg every 3 to 4 hours. At 10 kg, this child typically should receive 1.0 mg every 3 to 4 hours.
A 17-year-old client has been recently diagnosed as having diabetes mellitus Type 1. Insulin is prescribed. The client asks why insulin can't be taken by mouth. What is the best answer for the nurse to give?
- A. Insulin is irritating to the stomach.
- B. Oral insulin is too rapidly absorbed.
- C. Gastric juices destroy insulin.
- D. You can take it by mouth when the acute phase is over.
Correct Answer: C
Rationale: Insulin is a protein destroyed by gastric enzymes, requiring injection for effective delivery.