Nokea
The nurse is caring for a client with a history of heart failure who is receiving furosemide (Lasix). Which laboratory value should the nurse monitor closely?
- A. Serum potassium
- B. Serum calcium
- C. Serum glucose
- D. Serum cholesterol
Correct Answer: A
Rationale: Furosemide, a loop diuretic, can cause hypokalemia due to potassium loss in urine. Monitoring serum potassium is critical to prevent arrhythmias or muscle weakness.
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A postoperative nursing goal for the infant who has had surgery to correct imperforate anus is to prevent tension on the perineum. To achieve this goal, the nurse should not place the neonate on the:
- A. Abdomen, with legs pulled up under the body.
- B. Back, with legs suspended at a 90-degree angle.
- C. Left side, with hips elevated.
- D. Right side, with hips elevated.
Correct Answer: A
Rationale: The abdominal position with legs tucked increases perineal tension, risking surgical site strain, unlike the other positions.
A client with a history of chronic lymphocytic leukemia is prescribed rituximab (Rituxan). The nurse should monitor the client for which of the following side effects during infusion?
- A. Hypotension.
- B. Hyperglycemia.
- C. Infusion reactions.
- D. Weight loss.
Correct Answer: C
Rationale: Rituximab can cause infusion reactions, such as fever or chills, requiring close monitoring during administration.
You are working in a community pediatric health clinic. Which developmental task should you apply into your practice?
- A. You should apply the principles of initiative when caring for preschool children.
- B. You should apply the principles of sensorimotor thought when caring for preschool children.
- C. You should apply the principles of intimacy when caring for the adolescent.
- D. You should apply the principles of concrete operations when caring for the adolescent.
Correct Answer: A
Rationale: According to Erikson's developmental stages, preschool children (ages 3-5) are in the stage of Initiative vs. Guilt, where they develop a sense of purpose through exploration and play. This is the appropriate developmental task to apply in a pediatric clinic for this age group.
A client with a history of cirrhosis is admitted with ascites. Which dietary modification should the nurse recommend?
- A. Low-sodium diet
- B. High-protein diet
- C. Low-fat diet
- D. High-carbohydrate diet
Correct Answer: A
Rationale: A low-sodium diet reduces fluid retention in ascites, helping to manage symptoms in clients with cirrhosis.
You are providing care to a permanently disabled Iraqi war veteran who is 28 years of age. When he returned home from the war at the age of years of age 2 years ago he was deemed permanently disabled by both the Veterans Administration (VA) and the Social Security Administration. He receives a substantial monthly service connected disability check from the Veterans Administration and he has no spouse or legal dependents. Which type of governmental health insurance is he now entitled to?
- A. Only the VA health care services because he is not 65 years of age
- B. Medicare because he has been deemed permanently disabled for 2 years
- C. Medicaid because he is permanently disabled and not able to work
- D. Choices B and C
Correct Answer: B
Rationale: Individuals deemed permanently disabled by the Social Security Administration for at least 24 months are eligible for Medicare, regardless of age . The veteran is also eligible for VA healthcare, but option A incorrectly states 'only' VA services. Medicaid eligibility depends on income and state criteria, which are not confirmed here.