Nokea
The nurse is assessing a client with a history of heart failure who is receiving furosemide (Lasix). Which of the following findings would indicate a need to withhold the medication?
- A. Potassium level of 2.8 mEq/L.
- B. Blood pressure of 130/80 mmHg.
- C. Heart rate of 80 beats per minute.
- D. Urine output of 50 mL/hour.
Correct Answer: A
Rationale: hypokalemia is a side effect of furosemide; a potassium level of 2.8 mEq/L is low and requires intervention before administering the medication
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Which of the following are risk factors for developing glaucoma? Select all that apply.
- A. asthma
- B. pernicious anemia
- C. diabetes mellitus
- D. obesity
- E. hypertension
Correct Answer: C,E
Rationale: Diabetes mellitus and hypertension increase glaucoma risk by affecting ocular blood flow and pressure. Asthma, anemia, and obesity are not direct risk factors.
The nurse is caring for a client who is postoperative day 1 following a laparoscopic appendectomy. The client reports shoulder pain. Which of the following actions should the nurse take?
- A. Administer an analgesic as ordered.
- B. Notify the physician immediately.
- C. Explain that this is referred pain from residual gas.
- D. Place the client in a prone position.
Correct Answer: C
Rationale: shoulder pain after laparoscopic surgery is often due to referred pain from residual carbon dioxide used during the procedure
A pediatric client is admitted to the hospital for treatment of diarrhea caused by an infection with salmonella. Which of the following most likely contributed to the child's illness?
- A. Brushing the family dog
- B. Playing with a turtle
- C. Taking a pony ride
- D. Feeding the family cat
Correct Answer: B
Rationale: Turtles are common carriers of Salmonella, which can be transmitted to children through handling, leading to gastrointestinal infection.
Which of the following is the best indicator of the diagnosis of HIV?
- A. White blood cell count
- B. ELISA
- C. Western Blot
- D. Complete blood count
Correct Answer: C
Rationale: The Western Blot is the most specific test for confirming HIV diagnosis after a positive ELISA.
To minimize confusion in the elderly hospitalized client, the nurse should:
- A. Provide sensory stimulation by varying the daily routine
- B. Keep the room brightly lit and the television on to provide orientation to time
- C. Encourage visitors to limit visitation to phone calls to avoid overstimulation
- D. Provide explanations in a calm, caring manner to minimize anxiety
Correct Answer: D
Rationale: Calm, clear explanations reduce anxiety and confusion in elderly clients, promoting orientation and comfort in the hospital setting.