Nokea
The nurse is administering the loop diuretic furosemide (Lasix) to the client diagnosed with essential hypertension. Which assessment data would warrant the nurse to question administering the medication?
- A. The client's potassium level is 4.2 mEq/L.
- B. The client's urinary output is greater than the intake.
- C. The client has tented skin turgor and dry mucous membranes.
- D. The client has lost two (2) pounds in the last 24 hours.
Correct Answer: C
Rationale: Tented skin turgor and dry membranes indicate dehydration, a contraindication for Lasix, which could worsen fluid loss. Normal potassium, output, or weight loss are expected.
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A 4 year-old child is admitted with burns on his legs and lower abdomen. When assessing the child's hydration status, which of the following indicates a less than adequate fluid replacement?
- A. Decreasing hematocrit and increasing urine volume
- B. Rising hematocrit and decreasing urine volume
- C. Falling hematocrit and decreasing urine volume
- D. Stable hematocrit and increasing urine volume
Correct Answer: B
Rationale: Rising hematocrit and decreasing urine volume. A rising hematocrit indicates a decreased total blood volume, a finding consistent with dehydration.
The client with epilepsy is prescribed carbamazepine (Tegretol), an anticonvulsant. Which discharge instruction should the nurse include in the teaching?
- A. Wear SPF 15 sunscreen when outside.
- B. Obtain regular serum drug levels.
- C. Be sure to floss teeth daily.
- D. Instruct the client to take tub baths only.
Correct Answer: B
Rationale: Carbamazepine requires serum level monitoring to ensure therapeutic range and avoid toxicity. Sunscreen, flossing, or baths are less relevant.
A 10-month-old child has been diagnosed as having acute otitis media. The pediatrician prescribed amoxicillin suspension. What instructions should the nurse give the child's mother?
- A. When your child's temperature has been normal for two days, discontinue the medicine.
- B. Discard any unused medication.
- C. If your child has symptoms of an ear infection again, start giving her the leftover medication.
- D. Give your child all of the medication in the bottle.
Correct Answer: B
Rationale: The nurse should instruct to discard unused medication to prevent misuse. The full course should be completed, but the bottle is only good for two weeks.
The employee health nurse is observing a student nurse administer a PPD tuberculin test to a new employee. Which behavior would warrant immediate intervention by the employee health nurse?
- A. The student nurse inserts the needle at a 45-degree angle.
- B. The student nurse cleanses the forearm with alcohol.
- C. The student nurse circles the injection site with ink.
- D. The student nurse instructs the employee to return in three (3) days.
Correct Answer: A
Rationale: PPD tests require a 10–15-degree angle for intradermal injection to form a wheal; 45 degrees is incorrect and warrants intervention. Other actions are standard.
The nurse is evaluating the client's home medications and notes the client with angina is taking an antidepressant. Which intervention should the nurse implement because the client is taking this medication?
- A. Ask the client if there is a plan for suicide.
- B. Assess the client's depression on a 1-to-10 scale.
- C. Explain this medication cannot be taken because of the angina.
- D. Request a referral to the hospital psychologist.
Correct Answer: A
Rationale: Antidepressants in angina patients raise suicide risk concerns; assessing for a plan is the priority to ensure safety.