Nokea
The nurse is caring for a 10 year-old client who will be placed on heparin therapy. Which assessment is critical for the nurse to make before initiating therapy?
- A. Vital signs
- B. Weight
- C. Lung sounds
- D. Skin turgor
Correct Answer: B
Rationale: Weight. Check the client's weight because dosage is calculated on the basis of weight.
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The client in end-stage renal disease is a Jehovah's Witness. The HCP orders erythropoietin (Epogen), a biologic response modifier, subcutaneously for anemia. Which action should the nurse take?
- A. Question this order because of the client's religion.
- B. Encourage the client to talk to his or her minister.
- C. Administer the medication subcutaneously as ordered.
- D. Obtain the informed consent prior to administering.
Correct Answer: C
Rationale: Epogen is synthetic, not blood-derived, so it’s acceptable for Jehovah’s Witnesses. Administer as ordered; questioning, minister consultation, or consent are unnecessary.
The client is experiencing supraventricular tachycardia (SVT). Which antidysrhythmic medication should the nurse prepare to administer?
- A. Atropine.
- B. Amiodarone.
- C. Adenosine.
- D. Dobutamine.
Correct Answer: C
Rationale: Adenosine is first-line for SVT, rapidly terminating the arrhythmia, per ACLS guidelines. Other drugs are used for different rhythms.
An adult is scheduled for a left cataract extraction. Homatropine and Cyclogyl eye drops are ordered. What is the expected action of these drops?
- A. Mydriasis
- B. Miotic effects
- C. Relaxation of eye muscles
- D. Prevention of infection
Correct Answer: A
Rationale: Homatropine and Cyclogyl are mydriatics, dilating the pupil to facilitate cataract surgery.
The nurse is teaching a group of women in a community clinic about prevention of osteoporosis. Which of the following over-the-counter medications should the nurse recognize as having the most elemental calcium per tablet?
- A. Calcium chloride
- B. Calcium citrate
- C. Calcium gluconate
- D. Calcium carbonate
Correct Answer: D
Rationale: Calcium carbonate. Calcium carbonate contains 400 mg of elemental calcium in 1 gram of calcium carbonate.
A woman who is taking cortisone for an acute exacerbation of rheumatoid arthritis is upset about the fat face she has developed. She says to the nurse, 'I'm going to quit taking that cortisone.' The nurse's response should be based on which understanding?
- A. Cortisone does not cause a fat face.
- B. The symptoms will lessen as her body adjusts to the medication.
- C. The drug should be immediately discontinued when adverse effects occur.
- D. Cortisone should never be abruptly discontinued.
Correct Answer: D
Rationale: Abrupt discontinuation of cortisone can cause adrenal insufficiency; tapering is required to prevent complications.