Nokea
The nurse is preparing to administer IV furosemide to a client with chronic kidney disease. The nurse should administer the medication slowly to prevent
- A. oliguria
- B. ototoxicity
- C. bradycardia
- D. hypertension
Correct Answer: B
Rationale: Rapid IV furosemide can cause ototoxicity (B) in CKD patients due to drug accumulation. Oliguria (A) is already present, and furosemide does not typically cause bradycardia (C) or hypertension (D).
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The home health nurse is reinforcing teaching for a client with atrial fibrillation who is prescribed digoxin 0.25 mg orally on even-numbered days. Which client statement will require further teaching about digoxin?
- A. I will call the health care provider if I don't feel like eating.
- B. I will call the health care provider if I feel dizzy and lightheaded.
- C. I will call the health care provider if I have trouble reading.
- D. I will take my blood pressure before taking my medicine.
Correct Answer: D
Rationale: Taking blood pressure (D) is unrelated to digoxin monitoring. Anorexia (A Anorexia (A), dizziness (B), and visual changes (C) are signs of digoxin toxicity, requiring provider notification.
A housekeeping employee tells the staff nurse of having a headache and asks for acetaminophen. How should the nurse respond?
- A. Ask about liver disease and give acetaminophen from the nurse's personal supply
- B. Check for allergies to drugs before giving acetaminophen from hospital stock
- C. Check the employee's blood pressure
- D. Refer employee to the employee's health care provider
Correct Answer: D
Rationale: Nurses cannot dispense medications without a prescription (A, B). Checking blood pressure (C) is irrelevant. Referring to a provider (D) ensures proper evaluation and treatment.
A client with a diagnosis of HPV is at risk for which of the following?
- A. Hodgkin's lymphoma
- B. Cervical cancer
- C. Multiple myeloma
- D. Ovarian cancer
Correct Answer: B
Rationale: The client with HPV is at higher risk for cervical and vaginal cancer related to this STI. She is not at higher risk for the cancers mentioned in answers A, C, and D, so those are incorrect.
The wife of a 65 -year-old man says to the clinic nurse, 'I think the doctor should check out my husband's hearing. Either he is totally ignoring me and everyone else or he has a hearing problem.' How is the man likely to respond when the nurse asks him if he has difficulty hearing?
- A. I can hear women better than men.
- B. There's nothing wrong with my hearing. People around me just mumble a lot.
- C. I really need to get my hearing checked.
- D. Why should an old man like me care if he hears or not?
Correct Answer: B
Rationale: People who are losing their hearing usually complain that the people around them mutter. Denial is a very common response to hearing loss. Most older people who are having difficulties with hearing wait years before they will admit to hearing loss and accept treatment. Most older people who are losing their hearing hear lower frequencies (men's voices) better than higher frequencies (women's voices). Answer 4 not only indicates denial, but it also suggests that the client is in despair as opposed to ego integrity.
The nurse caring for a client with an ileal conduit observes that the stoma appears bluish gray. What is the nurse's best action?
- A. Administer an antibacterial agent and assess for additional signs of infection
- B. Document the findings and continue to monitor for changes
- C. Measure the stoma and obtain a larger pouching device
- D. Report the findings to the health care provider immediately
Correct Answer: D
Rationale: A bluish-gray stoma (D) indicates ischemia, requiring immediate reporting. Antibiotics (A) are premature, monitoring (B) delays care, and resizing the pouch (C) is irrelevant.