Nokea
The nurse is aware that the effect of antihypertensive drug therapy may be affected by a 75 year-old client's
- A. poor nutritional status
- B. decreased gastrointestinal motility
- C. increased splanchnic blood flow
- D. altered peripheral resistance
Correct Answer: B
Rationale: Decreased gastrointestinal motility, together with shrinkage of the gastric mucosa and changes in hydrochloric acid levels, will decrease absorption of medications and interfere with their actions.
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Delirium tremens could best be described as
- A. Disorganized thinking, feelings of terror and non-purposeful behavior
- B. A generalized shaking of the body accompanied by repetitive thoughts
- C. An excited state accompanied by disorientation, hallucination and tachycardia
- D. Single or multiple jerks caused by rapid contracting muscles
Correct Answer: C
Rationale: An excited state accompanied by disorientation, hallucination and tachycardia. Delirium tremens involves severe withdrawal symptoms, including confusion, hallucinations, and autonomic hyperactivity.
A 67-year-old man for an intravenous pyelogram (IVP).
The nurse prepares a 67-year-old man for an intravenous pyelogram (IVP). Which of the following information is MOST important for the nurse to obtain before the procedure?
- A. The date of the client's last EKG.
- B. The time of the client's last meal.
- C. A list of the client's allergies.
- D. A list of the medications the client takes at home.
Correct Answer: C
Rationale: Strategy: All answers are assessments. Determine why you would make the assessment and how it relates to the situation. (1) electrical activity of heart, not most important (2) should be NPO for 6-8 h, not most important (3) correct-involves injection of radiopaque dye, used to identify lesions and assess function, allergy to iodine is life-threatening (4) not most important
The nurse is caring for a client with a history of heart failure who is receiving lisinopril (Prinivil) 10 mg PO daily. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Potassium 5.5 mEq/L.
- B. Sodium 138 mEq/L.
- C. Creatinine 1.2 mg/dL.
- D. Calcium 9.0 mg/dL.
Correct Answer: A
Rationale: Hyperkalemia (potassium 5.5 mEq/L) is a serious complication of lisinopril, an ACE inhibitor, risking arrhythmias in heart failure. Options B, C, and D are normal: sodium 138 mEq/L, creatinine 1.2 mg/dL, and calcium 9.0 mg/dL do not indicate complications.
A client who has had an above-knee amputation (AKA) with an immediate prosthetic fitting.
It is MOST important for the nurse to
- A. assess drainage from Penrose drains.
- B. observe dressings for signs of excessive bleeding.
- C. elevate the stump for no less than 40 hours.
- D. provide cast care to the affected extremity.
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Is there an appropriate assessment? No. Determine the outcome of each implementation. (1) drains not usually used with amputations (2) rigid cast dressing frequently used to create a socket for prosthesis (3) elevation of extremity unnecessary, rigid cast dressing prevents swelling (4) correct-cast applied to provide uniform compression, prevent pain and contractures
The doctor writes an order for piperacillin (Pipracil) 3 g IV q6h for an adult client.
Before administering this drug, the nurse should
- A. check for known allergies to medications.
- B. ensure that the client's respiratory rate is over 12.
- C. administer dexamethasone sodium phosphate (Decadron) 2 mg IV stat.
- D. check the client's blood pressure both sitting and standing.
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Is this a situation that requires assessment? Yes. Is there an appropriate assessment? Yes. (1) correct-assessment, piperacillin (Pipracil) is a semisynthetic broad-spectrum penicillin, should not be administered to clients with known allergies (2) assessment, not relevant for administration of this medication (3) implementation, not relevant for administration of this medication (4) assessment, not relevant for administration of this medication