Nokea
The nurse is caring for assigned clients. Which of the following clients is at highest risk for developing delirium?
- A. 32-year-old client with gastroenteritis, dehydration, and a low-grade fever
- B. 55-year-old client with coronary artery disease who had coronary artery bypass surgery four days ago
- C. 60-year-old client with type 2 diabetes mellitus who had bilateral above-the-knee amputations two months ago
- D. 80-year-old client with chronic obstructive pulmonary disease, chronic respiratory failure, and urosepsis
Correct Answer: D
Rationale: The 80-year-old with COPD, respiratory failure, and urosepsis has multiple delirium risk factors: advanced age, infection, and chronic illness. Younger clients with less severe conditions have lower risk.
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The nurse is caring for several hospitalized children with the following diagnoses. Which disorder is likely to result in metabolic acidosis?
- A. Severe diarrhea for 24 hours
- B. Nausea with anorexia
- C. Alternating constipation and diarrhea
- D. Vomiting for over 48 hours
Correct Answer: A
Rationale: Severe diarrhea is the only problem listed that can lead to metabolic acidosis if untreated.
The client is receiving furosemide (Lasix) 80 mgm. Which is a sign of a possible complication of the administration of furosemide?
- A. Tachycardia
- B. Hypertension
- C. Polyuria
- D. Eupnea
Correct Answer: A
Rationale: Furosemide is a loop diuretic that can cause electrolyte imbalances, such as hypokalemia, which may lead to tachycardia. Hypertension is not a common complication; polyuria is an expected effect, not a complication; and eupnea (normal breathing) is unrelated.
A client with tuberculosis has an order for Rifadin (rifampin). What vitamin is usually given with rifampin?
- A. Thiamine
- B. Pyridoxine
- C. Folic acid
- D. Cyanocobalamin
Correct Answer: B
Rationale: Pyridoxine (vitamin B6) is given with rifampin to prevent peripheral neuropathy, a side effect. Other vitamins are not typically associated with rifampin therapy.
The nurse is caring for a client with Kawasaki disease. Which of the following actions would be a priority for the nurse to take?
- A. Monitor the client for gallop heart sounds and decreased urine output.
- B. Provide a quiet, nonstimulating, restful environment for the client.
- C. Apply cool compresses to the skin of the client's hands and feet.
- D. Offer the client soft foods and adequate amounts of clear liquids.
Correct Answer: B
Rationale: A quiet, restful environment reduces irritability and stress in Kawasaki disease, promoting recovery. Monitoring heart sounds/urine output is secondary, as cardiac complications are less immediate. Cool compresses and soft foods are less critical.
The nurse is caring for a client with deep venous thrombosis of the lower extremity. Which of the following findings would the nurse expect to observe? Select all that apply.
- A. dry, shiny, hairless skin on the affected extremity
- B. warmth and redness of the affected extremity
- C. reports of pain in the affected calf
- D. edema of the affected extremity
- E. cyanosis of the affected toes
Correct Answer: B,C,D
Rationale: DVT causes inflammation, leading to warmth, redness, pain, and edema in the affected extremity. Dry, shiny, hairless skin and cyanosis are more typical of arterial insufficiency, not DVT.