Nokea
The nurse is performing an assessment on a client who is cachectic and has developed an enterocutaneous fistula following surgery to relieve a small bowel obstruction. The client's total protein level is reported as 4.5 g/dl. Which of the following would the nurse anticipate?
- A. Additional potassium will be given IV
- B. Blood for coagulation studies will be drawn
- C. Total parenteral nutrition (TPN) will be started
- D. Serum lipase levels will be evaluated
Correct Answer: C
Rationale: The client is not absorbing nutrients adequately as evidenced by the cachexia and low protein levels. (A normal total serum protein level is 6.0-8.0 g/dl.) TPN will promote a positive nitrogen balance in this client who is unable to digest and absorb nutrients adequately.
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A patient with generalized anxiety disorder is prescribed buspirone (Buspar). Which of the following statements indicates the patient understands the medication?
- A. I will take this medication only when I feel anxious.
- B. This medication may cause dependence.
- C. It may take a few weeks to feel the full effect.
- D. I can drink alcohol while taking this medication.
Correct Answer: C
Rationale: Buspirone takes 2–4 weeks for full anxiolytic effect, requiring consistent use. It’s not PRN, has low dependence risk, and alcohol should be avoided due to CNS depression.
Which of the following medications is a serotonin antagonist that might be used to relieve nausea and vomiting?
- A. metoclopramide (Reglan)
- B. ondansetron (Zofran)
- C. hydroxyzine (Vistaril)
- D. prochlorperazine (Compazine)
Correct Answer: B
Rationale: Ondansetron is a serotonin (5-HT3) receptor antagonist effective for nausea and vomiting, particularly in chemotherapy or postoperative settings. The other medications have different mechanisms. Physiological Adaptation
The nurse suggests that they bring foods low in sodium such as:
- A. Ice cream
- B. Celery sticks
- C. Fresh oranges
- D. Peanut butter cookies
Correct Answer: C
Rationale: Fresh oranges are naturally low in sodium, suitable for a low-sodium diet.
The nurse is reviewing a client's pre-op lab values. Which of the following lab results warrants immediate attention?
- A. Prothrombin time of 1 minute and 20 seconds
- B. Hematocrit $38 \mathrm{~mL} / \mathrm{dL}$
- C. Hemoglobin $14 \mathrm{~g} / \mathrm{dL}$
- D. White blood count $6,000 / \mathrm{mm}$
Correct Answer: A
Rationale: A prothrombin time of 1 minute and 20 seconds is significantly prolonged, indicating a bleeding risk that requires immediate attention before surgery.
The morning staff of an inpatient psychiatric unit has just completed the change of shift report. The nurse should give priority to assessing the client:
- A. With schizophrenia having auditory hallucinations
- B. Scheduled for electroconvulsive therapy
- C. With a lithium level of 1.8 mEq/L
- D. Receiving Thorazine (chlorpromazine) with a WBC of 7,500 cu mm
Correct Answer: C
Rationale: A lithium level of 1.8 mEq/L is above the therapeutic range (0.6-1.2 mEq/L) and indicates potential toxicity, requiring immediate assessment. Answer A is important but less urgent unless the hallucinations are commanding harm. Answer B is incorrect as the client is only scheduled for therapy, not in immediate danger. Answer D is within normal WBC range and less critical.