Nokea
The nurse is assisting in the assessment of the patient admitted with 'extreme abdominal pain.' The nurse asks the client about the medication that he has been taking because:
- A. Interactions between medications will cause abdominal pain.
- B. Various medications taken by mouth can affect the alimentary tract.
- C. This will provide an opportunity to educate the patient regarding the medications used.
- D. The types of medications might be attributable to an abdominal pathology not already identified.
Correct Answer: D
Rationale: Medications can cause or exacerbate abdominal pathology, making it essential to assess their role in the patient's symptoms.
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The nurse is reviewing the lab results of four clients. Which finding should be reported to the physician?
- A. A client with chronic renal failure with a serum creatinine of 5.6 mg/dL
- B. A client with rheumatic fever with a positive C reactive protein
- C. A client with gastroenteritis with a hematocrit of 52%
- D. A client with epilepsy with a white cell count of 3,800 mm³
Correct Answer: C
Rationale: A hematocrit of 52% in gastroenteritis suggests dehydration, which requires immediate reporting.
A client prescribed furosemide (Lasix) should choose which meal for lunch?
- A. chicken breast, white rice, apple
- B. turkey sandwich on wheat bread, celery sticks, grapefruit
- C. egg salad, cooked carrots, strawberries
- D. baked salmon, spinach salad, banana
Correct Answer: D
Rationale: Furosemide causes potassium loss. A meal with potassium-rich foods (e.g., spinach, banana) helps maintain electrolyte balance.
A client with recurrent episodes of gout has been advised to eat a low-purine diet. Which of the following foods should the nurse advise him to limit or avoid? Select all that apply.
- A. Liver.
- B. Sardines.
- C. Wine.
- D. Low-fat yogurt.
- E. Beef broth.
- F. Potatoes.
Correct Answer: A,B,E
Rationale: High-purine foods like liver (A), sardines (B), and beef broth (E) should be limited to reduce gout flare-ups. Wine (C), low-fat yogurt (D), and potatoes (F) are low in purines and generally safe.
The floor nurse sees a new order in a client's chart for levothyroxine (Synthroid) 125 mcg PO every day. The pharmacy sends up Synthroid 0.1 mg tablets. How many tablets should the nurse administer? Calculate and fill in the blank.
Correct Answer: 1.25
Rationale: 125 mcg = 0.125 mg. 0.125 mg ÷ 0.1 mg/tablet = 1.25 tablets.
The nurse is caring for a client with a wound that presents with full-thickness tissue loss and eschar covering the wound bed. The nurse would record this wound as which stage?
- A. Stage I
- B. Stage II
- C. Stage III
- D. Stage IV
- E. unstageable
Correct Answer: E
Rationale: Eschar covering the wound bed makes it unstageable, as the depth cannot be assessed until debridement.