Nokea
The nurse is developing a plan of care for the client with viral hepatitis. The nurse should instruct the client to:
- A. Obtain adequate bed rest.
- B. Increase fluid intake.
- C. Follow a high-protein diet.
- D. Avoid carbohydrates.
Correct Answer: A
Rationale: Adequate bed rest (A) reduces metabolic demands and supports recovery in viral hepatitis. Increased fluids (B) are supportive but secondary. High-protein diets (C) or avoiding carbohydrates (D) are not indicated for hepatitis management.
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A short time after cataract surgery, the client complains of nausea. The nurse should first:
- A. Instruct the client to take a few deep breaths until the nausea subsides.
- B. Explain that this is a common feeling that will pass quickly.
- C. Tell the client to call the nurse promptly if vomiting occurs.
- D. Administer an antiemetic, as ordered.
Correct Answer: D
Rationale: Nausea after cataract surgery can indicate increased intraocular pressure or other complications. Administering an antiemetic as ordered is the priority to prevent vomiting, which could increase intraocular pressure and cause complications.
A client with acute renal failure has a low calcium level. The nurse should monitor for:
- A. Tetany.
- B. Hypertension.
- C. Bradycardia.
- D. Edema.
Correct Answer: A
Rationale: Low calcium can cause tetany, manifesting as muscle cramps or spasms.
A client who has had her jaws wired begins to vomit. What should be the nurse's first action?
- A. Insert a nasogastric (NG) tube and connect it to suction.
- B. Use wire cutters to cut the wire.
- C. Suction the client's airway as needed.
- D. Administer an antiemetic intravenously.
Correct Answer: C
Rationale: Suctioning the airway is the first action to prevent aspiration in a client with wired jaws who is vomiting. Cutting the wires is a last resort, and the other options do not address the immediate risk of airway obstruction.
The nurse has an order to administer sulfasalazine (Azulfidine) 2 g. The medication is available in 500-mg tablets. How many tablets should the nurse administer?
- A. 2 tablets.
- B. 3 tablets.
- C. 4 tablets.
- D. 5 tablets.
Correct Answer: C
Rationale: To administer 2 g (2000 mg) of sulfasalazine with 500-mg tablets, divide 2000 by 500, which equals 4 tablets. CN: Pharmacological and parenteral therapies; CL: Apply
While caring for a client who has sustained a myocardial infarction (MI), the nurse notes eight premature ventricular contractions (PVCs) in 1 minute on the cardiac monitor. The client is receiving an I.V. infusion of 5% dextrose in water (D5W) and oxygen at 2 L/minute. The nurse's first course of action should be:
- A. Increase the I.V. infusion rate.
- B. Notify the physician promptly.
- C. Increase the oxygen concentration.
- D. Administer a prescribed analgesic.
Correct Answer: B
Rationale: Frequent PVCs (eight per minute) may indicate irritability of the myocardium, risking serious arrhythmias. Notifying the physician promptly ensures timely intervention, such as antiarrhythmic therapy.