Nokea
The nurse is administering terbutaline (Brethine) to a client in labor. Prior to administration of the medication, the nurse assesses the client's pulse to be 144. The nurse's priority action should be to
- A. withhold the medication.
- B. decrease the dose by half.
- C. administer the medication.
- D. wait 15 minutes, then recheck the rate.
Correct Answer: A
Rationale: Terbutaline, a tocolytic, can cause maternal tachycardia. A pulse of 144 indicates significant tachycardia, a side effect requiring the medication to be withheld to prevent further cardiovascular strain. Decreasing the dose (B) is not within nursing scope, administering (C) ignores the risk, and waiting (D) delays intervention.
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The nurse observes a LPN/LVN perform a wet-to-dry dressing change on a 2-inch abdominal incision. Which of the following behaviors, if performed by the LPN/LVN, would indicate an understanding of proper technique?
- A. A clean cotton ball is used to cleanse from the top of the incision to the bottom of the incision using long strokes.
- B. The incision is packed with sterile gauze, and then sterile saline is poured over the dressing.
- C. The nurse packs wet gauze into the incision without overlapping it onto the skin.
- D. The old dressing is saturated with sterile saline before it is removed.
Correct Answer: C
Rationale: Wet-to-dry dressings should have wet gauze packed into the incision without overlapping onto the skin to prevent skin breakdown. Cleansing (A) should be from the center outward, dressings (B) are soaked before packing, and old dressings (D) are removed dry to debride the wound.
Teaching about the need to avoid foods high in potassium is most important for which client?
- A. a client receiving diuretic therapy
- B. a client with an ileus
- C. a client with metabolic alkalosis
- D. a client with renal disease
Correct Answer: D
Rationale: Renal disease impairs potassium excretion, leading to hyperkalemia, so avoiding high-potassium foods is critical. The other conditions are more associated with hypokalemia. Physiological Adaptation
A nurse is caring for a patient with diabetes mellitus who is experiencing hyperglycemia. Which of the following interventions should the nurse implement? (Select all that apply)
- A. Administer insulin as prescribed
- B. Provide sugar-free fluids
- C. Encourage carbohydrate-rich snacks
- D. Monitor blood glucose levels regularly
- E. Assess for signs of diabetic ketoacidosis (DKA)
Correct Answer: A,B,D,E
Rationale: Insulin corrects hyperglycemia, sugar-free fluids prevent dehydration, monitoring tracks progress, and DKA assessment detects complications. Carbohydrate snacks worsen hyperglycemia.
A client has returned to his room following an esophagoscopy. Before offering fluids, the nurse should give priority to assessing the client's:
- A. Level of consciousness
- B. Gag reflex
- C. Urinary output
- D. Movement of extremities
Correct Answer: B
Rationale: Assessing the gag reflex is critical post-esophagoscopy to ensure the client can swallow safely, as local anesthesia may impair this reflex.
The physician has ordered IV replacement of potassium for a patient with severe hypokalemia.
The nurse would administer the IV potassium
- A. by rapid bolus.
- B. diluted in 100 cc over 1 hour.
- C. diluted in 10 cc over 10 minutes.
- D. IV push.
Correct Answer: B
Rationale: Potassium is diluted and infused slowly to prevent cardiac arrhythmias.