Nokea
The nurse is caring for a client who is receiving IV gentamicin for a gram-negative infection. Which of the following laboratory results should the nurse report immediately?
- A. Creatinine 2.0 mg/dL.
- B. Sodium 140 mEq/L.
- C. Potassium 4.0 mEq/L.
- D. Hemoglobin 13 g/dL.
Correct Answer: A
Rationale: A creatinine of 2.0 mg/dL indicates nephrotoxicity, a serious gentamicin side effect. Options B, C, and D are normal.
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The nurse is caring for a client who is receiving a continuous IV infusion of propofol (Diprivan) for sedation. Which of the following findings would be of GREATest concern to the nurse?
- A. Respiratory rate of 12 breaths/min.
- B. Blood pressure of 100/60 mmHg.
- C. Heart rate of 80 bpm.
- D. Oxygen saturation of 90%.
Correct Answer: D
Rationale: An oxygen saturation of 90% is low, indicating hypoxemia, a serious complication of propofol due to respiratory depression, requiring immediate intervention. Options A, B, and C are acceptable: respiratory rate 12 breaths/min, blood pressure 100/60 mmHg, and heart rate 80 bpm are stable.
A child is admitted with acute glomerulonephritis. Which finding in the client's history is most consistent with the diagnosis?
- A. A recent tick bite
- B. Pharyngitis two weeks ago
- C. A mosquito bite last week
- D. Ingestion of foods high in uric acid
Correct Answer: B
Rationale: Acute glomerulonephritis is often post-streptococcal, following pharyngitis by 1-3 weeks, due to immune complex deposition in glomeruli. Tick bites, mosquito bites, or uric acid are unrelated.
Which play activity is most appropriate for a 15-month-old with a cyanotic heart defect?
- A. Push-and-pull toy
- B. Mobile
- C. Shape sorter
- D. Pounding board
Correct Answer: B
Rationale: A mobile is a passive activity suitable for a 15-month-old with a cyanotic heart defect, as it avoids exertion, so B is correct. Push-and-pull toys , shape sorters , and pounding boards require more physical effort.
The nurse is performing hypertension screening at the local grocery store. It would be MOST important for the nurse to complete which of the following tasks?
- A. Use a blood pressure cuff that overlaps the arm at least four inches.
- B. Support the client's arm above the level of the heart.
- C. Take two readings at least five minutes apart.
- D. Take the blood pressure after the client has exercised for 10 minutes.
Correct Answer: C
Rationale: Two readings five minutes apart ensure accuracy in hypertension screening. Options A, B, and D are incorrect techniques.
The nurse is caring for a client who is receiving IV fluids at 100 mL/hour. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood pressure of 130/80 mmHg.
- B. Heart rate of 80 bpm.
- C. Shortness of breath and crackles.
- D. Urine output of 50 mL/hour.
Correct Answer: C
Rationale: Shortness of breath and crackles suggest fluid overload, a serious complication of IV fluids, potentially leading to pulmonary edema. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 80 bpm, and urine output 50 mL/hour indicate stability.