Nokea
Laboratory reference ranges
Glucose (fasting)
70-110 mg/dL
(3.9-6.1 mmol/L)
Potassium
3.5-5 mEq/L
(3.5-5 mmol/L)
The nurse is administering prescribed medications to assigned clients. The nurse should hold and seek clarification for which scheduled administrations? Select all that apply.
- A. client with cirrhosis had 2 stools today, lactulose prescribed daily
- B. client receiving IV vancomycin; mild facial flushing noted after 30 minutes
- C. client scheduled for abdominal surgery tomorrow; vitamin E PO prescribed daily
- D. client prescribed lisinopril PO daily; serum potassium level is 5.6 mEq/L (5.6 mmol/L)
- E. client with diabetes mellitus has insulin glargine and aspart prescribed, AM glucose is 100 mg/dL (5.6 mmol/L)
Correct Answer: B, C, D
Rationale: Vancomycin flushing (B) suggests red man syndrome, vitamin E (C) increases bleeding risk pre-surgery, and hyperkalemia (D) contraindicates lisinopril. Lactulose (A) and insulin (E) are appropriate.
You may also like to solve these questions
A client who received complete thickness burns at 7:30 a.m. was rushed to the emergency room where IV therapy with Lactated Ringer's was begun. He is to receive $8,000 \mathrm{~mL}$ of solution in 24 hours. According to the Parkland formula, how much solution should he receive by 11:30 p.m.?
- A. 4,000 mL
- B. 5,000 mL
- C. 6,000 mL
- D. 7,000 mL
Correct Answer: C
Rationale: The Parkland formula states half the total fluid (4,000 mL) is given in the first 8 hours (by 3:30 p.m.), and the remaining 4,000 mL over the next 16 hours. By 11:30 p.m. (16 hours post-burn), the client should have received 6,000 mL.
The parents of a 15 month-old child asks the nurse to explain their child's lab results and how they show the child has iron deficiency anemia. The nurse's best response is
- A. Although the results are here, your doctor will explain them later.
- B. Your child has fewer red blood cells that carry oxygen.
- C. The blood cells that carry nutrients to the cells are too large.
- D. There are not enough blood cells in your child's circulation.
Correct Answer: B
Rationale: Your child has fewer red blood cells that carry oxygen. This provides a simple explanation of iron deficiency anemia.
The nurse observes an ambulating client begin to experience a tonic-clonic seizure. Which nursing actions should be implemented immediately? Select all that apply.
- A. Guide the client to the floor and gently cradle the head
- B. Insert a tongue blade to prevent client from swallowing the tongue
- C. Move objects that may cause injury away from the client
- D. Physically restrain the client to prevent injury
- E. Place the client in left lateral position
- F. Remain with the client, observe, and record the seizure activity
Correct Answer: A, C, E, F
Rationale: Guiding to the floor (A), clearing objects (C), positioning laterally (E), and observing (F) ensure safety. Tongue blades (B) are dangerous, and restraining (D) increases injury risk.
A newborn has been diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize
- A. They can expect the child will be mentally retarded
- B. Administration of thyroid hormone will prevent problems
- C. This rare problem is always hereditary
- D. Physical growth/development will be delayed
Correct Answer: B
Rationale: Administration of thyroid hormone will prevent problems. Early identification and continued treatment with hormone replacement corrects this condition.
After inserting an indwelling catheter into an adult male, the nurse secures the catheter by:
- A. taping it lateral to the client's thigh.
- B. taping it upward to the client's abdomen.
- C. taping it downward to the client's thigh.
- D. making a loop with the tubing and taping the tubing to the client's thigh.
Correct Answer: A
Rationale: Taping the catheter laterally to the thigh prevents tension or dislodgement while allowing mobility. Upward or downward taping risks kinking, and looping increases infection risk.