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 would be of GREATest concern to the nurse?
- A. Potassium 3.2 mEq/L.
- B. Sodium 138 mEq/L.
- C. Creatinine 1.0 mg/dL.
- D. Glucose 100 mg/dL.
Correct Answer: A
Rationale: Furosemide, a loop diuretic, can cause hypokalemia, and a potassium level of 3.2 mEq/L is low, increasing the risk of arrhythmias in heart failure. Options B, C, and D are normal: sodium 138 mEq/L, creatinine 1.0 mg/dL, and glucose 100 mg/dL do not require immediate action.
You may also like to solve these questions
During the rehabilitative phase, the client's burns become infected with pseudomonas. The topical dressing most likely to be ordered for the client is:
- A. Silver sulfadiazine (Silvadene)
- B. Poviodine (Betadine)
- C. Mafenide acetate (Sulfamylon)
- D. Silver nitrate
Correct Answer: C
Rationale: Mafenide acetate (Sulfamylon) is particularly effective against Pseudomonas infections due to its broad-spectrum antibacterial activity and ability to penetrate eschar. Silver sulfadiazine is less effective against Pseudomonas, and povidone-iodine and silver nitrate are not the primary choices for Pseudomonas infections. Answers A, B, and D are incorrect because they are less effective for this specific infection.
The nurse is caring for a client with a suspected pulmonary embolism.
- A. Which diagnostic Test should the nurse anticipate for a client with a suspected pulmonary embolism?
- B. Chest X-ray.
- C. D-dimer blood Test .
- D. Electrocardiogram (ECG).
- E. Arterial blood gas (ABG).
Correct Answer: B
Rationale: A D-dimer blood Test is a sensitive screening tool for pulmonary embolism, detecting fibrin degradation products from a clot. Chest X-ray and ECG are non-specific, and ABG assesses oxygenation but not the diagnosis directly.
A baby boy is delivered after a rapid labor of three hours. What nursing action takes priority in the immediate newborn period?
- A. Suctioning with a bulb syringe
- B. Wrapping the baby in warm blankets
- C. Applying identification bracelets and taking footprints
- D. Assigning an APGAR score
Correct Answer: A
Rationale: Suctioning with a bulb syringe clears airways, ensuring respiratory patency, the priority in the immediate newborn period to prevent aspiration.
A 56-year-old male is admitted with a diagnosis of gastroesophageal reflux disease (GERD). The client is most likely to report esophageal discomfort following a meal of:
- A. Chicken in lemon sauce, rice, and fruit juice
- B. Turkey, salad, and a glass of red wine
- C. Poached salmon, mashed potatoes, and milk
- D. Hamburger, peas, and cola
Correct Answer: D
Rationale: Hamburger and cola are high-fat and carbonated, respectively, both of which exacerbate GERD symptoms.
Under the supervision of the registered nurse, a student nurse is changing the dressing of a 49-year-old woman with a newly inserted peritoneal dialysis catheter. Which of the following activities, if performed by the student nurse after removal of the old dressing, would require an intervention by the registered nurse?
- A. The student nurse cleans the catheter insertion site using a sterile cotton swab soaked in povidone-iodine.
- B. The student nurse applies two sterile precut 4 × 4s to the catheter insertion site.
- C. The student nurse cleans the insertion site using a circular motion from the outer abdomen toward the insertion site.
- D. The student nurse securely tapes the edges of the sterile dressing with paper tape.
Correct Answer: C
Rationale: should clean from insertion site outward toward outer abdomen