Nokea
The nurse is caring for a client who has bleeding esophageal varices. What should the nurse expect might develop in this client? Select all that apply.
- A. Confusion
- B. Tarry stools
- C. Lower abdominal pain and pressure
- D. High blood pressure
- E. Tremors
- F. Hallucinations
Correct Answer: A,B
Rationale: Bleeding varices cause blood loss, leading to tarry stools (melena) from digested blood and confusion from hepatic encephalopathy due to liver dysfunction. Abdominal pain, hypertension, tremors, or hallucinations are less directly related.
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A client with cancer has been placed on TPN. The nurse notes air entering the client via the central line. Which initial action is most appropriate?
- A. Notify the physician.
- B. Elevate the head of the bed.
- C. Place the client in the left lateral decubitus position.
- D. Stop the TPN and hang D51/2 NS.
Correct Answer: C
Rationale: The client is at risk for an air embolus. Placing the client in this position displaces air away from the right ventricle. Answers B and D would not help, so they are incorrect, and answer A would not be done first, so it's incorrect.
An RN who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN?
- A. A middle-aged client who says 'I took too many diet pills' and 'my heart feels like it is racing out of my chest.'
- B. A young adult who says 'I hear songs from heaven. I need money for beer. I quit drinking 2 days ago for my family. Why are my arms and legs jerking?'
- C. An adolescent who was recently diagnosed with leukemia and started chemotherapy with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10
- D. An elderly client who reports having taken a 'large crack hit' 10 minutes prior to walking into the emergency room
Correct Answer: C
Rationale: Nurses who are floated to other units should be assigned to a client who has minimal anticipated immediate complications of their problem. The client in option C exhibits opioid toxicity with the pinpoint pupils and has the least risk of complications occurring in the near future.
The nurse is caring for an infant who has a prescription for amoxicillin 25 mg/kg/day in 2 divided doses. The client weighs 16.5 lb (7.5 kg). The nurse has amoxicillin oral suspension 125 mg/5 mL available. How many mL should the nurse administer to the client with each dose? Record your answer using 2 decimal places.
Correct Answer: 3.75 mL/dose
Rationale: Calculation: 7.5 kg × 25 mg/kg/day = 187.5 mg/day. Divided into 2 doses = 93.75 mg/dose. 125 mg/5 mL = 25 mg/mL. 93.75 mg ÷ 25 mg/mL = 3.75 mL/dose (A).
A client is admitted with infective endocarditis (IE). Which finding would alert the nurse to a complication of this condition?
- A. dyspnea
- B. heart murmur
- C. macular rash
- D. Hemorrhage
Correct Answer: B
Rationale: Large, soft, rapidly developing vegetations attach to the heart valves. They have a tendency to break off, causing emboli and leaving ulcerations on the valve leaflets. These emboli produce findings of cardiac murmur, fever, anorexia, malaise and neurologic sequelae of emboli.
A client has been on lithium carbonate therapy for 7 days. Which of the following findings would be most important to report to the health care provider?
- A. Diarrhea, vomiting, and mild tremor
- B. Dry mouth and mild thirst
- C. Hyperactivity and auditory hallucinations
- D. Lithium level of 1.3 mEq/L (1.3 mmol/L)
Correct Answer: A
Rationale: Diarrhea, vomiting, and tremor (A) suggest lithium toxicity, requiring immediate reporting. Dry mouth (B) is common, hallucinations (C) are unrelated, and a lithium level of 1.3 (D) is within therapeutic range.