Nokea
The nurse is caring for a client who is receiving a continuous IV infusion of furosemide (Lasix) for heart failure. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Potassium 3.0 mEq/L.
- B. Sodium 138 mEq/L.
- C. Creatinine 1.2 mg/dL.
- D. Calcium 9.0 mg/dL.
Correct Answer: A
Rationale: Hypokalemia (potassium 3.0 mEq/L) is a serious complication of furosemide, increasing the risk of 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.
You may also like to solve these questions
The nurse observes that a child with muscular dystrophy has a positive Gower's sign. The nurse documents that the child:
- A. Has weak deep tendon reflexes
- B. Must use his hands to rise from the floor
- C. Has increased spinal reflexes
- D. Rocks back and forth in rhythmical fashion
Correct Answer: B
Rationale: A positive Gower's sign indicates the child uses their hands to push up from the floor due to muscle weakness, so B is correct. Answers A, C, and D do not describe Gower's sign.
A client with a neurological disorder.
Which of the following nursing assessments will be MOST helpful in determining subtle changes in the client's level of consciousness?
- A. Client posturing.
- B. Glasgow coma scale.
- C. Client thinking pattern.
- D. Occurrence of hallucinations.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) indicates increased intracranial pressure (2) correct-Glasgow coma scale score best evaluates changes in a client's level of consciousness by evaluating eye-opening, motor, and verbal responses (3) more appropriate for the psychiatric client (4) more appropriate for the psychiatric client
The nurse is caring for a client with a history of depression who is receiving bupropion (Wellbutrin) 150 mg PO bid. Which of the following client statements would be of GREATest concern to the nurse?
- A. I have a dry mouth.
- B. I feel restless sometimes.
- C. I think about ending my life.
- D. I take my medication with food.
Correct Answer: C
Rationale: Thoughts of ending life indicate suicidal ideation, a medical emergency requiring immediate intervention in a client on bupropion. Options
A fifty-five year-old man suffered a left frontal lobe CVA. The patient's family is not present in the room. Which of the following should the nurse watch most closely for?
- A. Changes in emotion and behavior
- B. Monitor loss of hearing
- C. Observe appetite and vision deficits
- D. Changes in facial muscle control
Correct Answer: A
Rationale: The frontal lobe is responsible for behavior and emotions.
The nurse notes dark red blood and a few clots in the catheter of a client two days after a transurethral prostatectomy (TURP). The nurse should first:
- A. Prepare the client for a return to surgery.
- B. Apply traction to the urethral catheter.
- C. Document the findings as normal.
- D. Decrease the client's oral fluid intake.
Correct Answer: B
Rationale: The appearance of dark red blood with a few clots indicates a venous bleed. Traction to the urethral catheter and increasing the client's fluid intake should be tried first before calling the doctor. Answer A would be indicated for the client with an arterial bleed, which is characterized by the appearance of bright red blood and many clots in the catheter, so it is incorrect.