Nokea
The nurse is caring for a client with a history of heart failure who is receiving furosemide (Lasix) 40 mg PO daily. Which of the following laboratory results should the nurse report immediately?
- A. Potassium 3.0 mEq/L.
- B. Sodium 140 mEq/L.
- C. Creatinine 1.2 mg/dL.
- D. Glucose 100 mg/dL.
Correct Answer: A
Rationale: Hypokalemia (3.0 mEq/L) from furosemide increases arrhythmia risk in heart failure. Options B, C, and D are normal.
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The nurse should observe for side effects associated with the use of bronchodilators. A common side effect of bronchodilators is:
- A. Tinnitus
- B. Tachycardia
- C. Ataxia
- D. Hypotension
Correct Answer: B
Rationale: Tachycardia is a common side effect of bronchodilators, such as beta-agonists, due to their stimulatory effect on the sympathetic nervous system.
A nine-month-old child with complaints of a fever of 102.2°F (39°C) and frequent vomiting.
The nurse would expect which of the following reflexes to still be present?
- A. Babinski's reflex.
- B. Moro's reflex.
- C. Tonic neck reflex.
- D. Grasp reflex.
Correct Answer: A
Rationale: Strategy: Think about growth and development. (1) correct-stroking outer sole of foot upward causes toes to hyperextend and fan and great toe to dorsiflex, disappears after one year of age (2) sudden jarring causes extension and abduction of extremities and fanning of fingers with index finger and thumb forming a C shape, disappears after 3-4 months (3) when head is turned to side, arm and leg extend on that side, and opposite arm and leg flex, disappears by age 3-4 months (4) touching palms of hands or soles of feet causes flexion of hands and toes, palmar grasp disappears after 3 months of age, plantar grasp lessened by 8 months of age
The nurse is transcribing the following physician's orders.
Which of the following orders warrants further clarification?
- A. Administer haloperidol (Haldol) 5 mg.
- B. Instruct client to use incentive spirometer q1h while awake.
- C. D5W 1/4 NS + KCl 20 mEq/L at 100 mL/h.
- D. CBC with differential and platelets at 8 AM.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-has no route of administration or schedule (2) clear and complete and needs no further clarification (3) clear and complete and needs no further clarification (4) clear and complete and needs no further clarification
A clinic nurse is taking a health history from a 34-year-old man newly diagnosed with Buerger's disease. The nurse would expect the client's complaints to include
- A. heart palpitations.
- B. dizziness when walking.
- C. blurred vision.
- D. digital sensitivity to cold.
Correct Answer: D
Rationale: vasculitis of blood vessels in upper and lower extremities
The nurse is caring for a client receiving warfarin (Coumadin) 5 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I eat a salad with spinach every day.
- B. I take ibuprofen for my headaches.
- C. I drink a glass of red wine with dinner.
- D. I walk for 30 minutes every morning.
Correct Answer: B
Rationale: Ibuprofen, an NSAID, increases bleeding risk when taken with warfarin, a significant concern due to potential for hemorrhage. Options A, C, and D are less critical: spinach (vitamin K) may require dose adjustment, moderate wine is generally safe, and walking is beneficial.