Nokea
The nurse is caring for a client with a history of heart failure who is receiving torsemide (Demadex) 20 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) is a serious torsemide side effect, risking arrhythmias in heart failure. Options B, C, and D are normal.
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Which of the following snacks would be suitable for a child with gluten-induced enteropathy?
- A. A soft oatmeal cookie
- B. Buttered popcorn
- C. A peanut butter and jelly sandwich
- D. Cheese pizza
Correct Answer: B
Rationale: Buttered popcorn is gluten-free, making it suitable for a child with celiac disease (gluten-induced enteropathy). The other options contain gluten.
A nurse performing actions that would be considered negligence.
Which of the following actions, if performed by the nurse, would be considered negligence?
- A. The nurse performs range-of-motion (ROM) exercises for a client with second- and third-degree burns of the chest.
- B. The nurse sits with a client who suffers from depression while he eats his lunch.
- C. The nurse caring for a client with myasthenia gravis administers the 7 AM dose of neostigmine bromide (Prostigmin) PO at 7:45 AM.
- D. The nurse instructs a 15-year-old girl who is sexually active about different types of contraceptives without consulting her parents.
Correct Answer: C
Rationale: Strategy: 'Negligence' indicates an incorrect action. (1) minimizes muscle atrophy (2) promotes eating, offer more frequent feedings of favorite foods (3) correct-delay in medication may cause difficulty in swallowing, might have difficulty taking medication (4) minor can request birth control without the parent's consent
A client with chronic bronchitis is admitted with complaints of chest pain. Which of the following drug orders should the nurse question?
- A. Nitroglycerin (Nitrostat)
- B. Cephalexin (Keflex)
- C. Propranolol (Inderal)
- D. Verapamil (Calan)
Correct Answer: C
Rationale: Propranolol, a beta-blocker, can exacerbate bronchoconstriction in chronic bronchitis, worsening respiratory symptoms. Nitroglycerin, cephalexin, and verapamil are less likely to pose issues in this context.
The mother of a 2-month-old child asks the nurse when she should start her son on solids. He is taking about 30 oz of formula per day. How should the nurse respond?
- A. This is a good time to begin.'
- B. When he is taking a quart per day.'
- C. Babies usually are ready for solids between 4 and 6 months of age.'
- D. Each baby is different. Some are ready sooner than others.'
Correct Answer: C
Rationale: Solids are typically introduced between 4-6 months when infants have better head control and digestive maturity, not at 2 months or based on formula volume.
A client who has been complaining of dysuria, urinary frequency, and discomfort in the suprapubic area.
After evaluating the results, the nurse should order a repeat urinalysis based on which of the following findings?
- A. Negative glucose.
- B. RBCs present.
- C. No WBCs or RBCs reported.
- D. Specific gravity 1.018.
Correct Answer: C
Rationale: Strategy: Determine the significance of each answer choice and how it relates a bladder infection. (1) glucose increases during the inflammation process; it is not a primary component in determining urinary tract infections (2) not as complete a response as answer choice #3 (3) correct-with the client's complaints, WBCs and RBCs should be present; WBCs are a response to the inflammation process and irritation of the urethra; RBCs are increased when bladder mucosa is irritated and bleeding (4) indicates the concentration of the urine