The nurse is reviewing laboratory reports for a client who is taking allopurinol (Zyloprim). Which of the following indicate that the drug has had a therapeutic effect?
- A. Decreased urine alkaline phosphatase level.
- B. Increased urine calcium excretion.
- C. Increased serum calcium level.
- D. Decreased serum uric acid level.
Correct Answer: D
Rationale: Allopurinol reduces serum uric acid levels, indicating therapeutic effectiveness in preventing uric acid stone formation.
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The nurse is assessing a client who has had a myocardial infarction (MI). The nurse notes the cardiac rhythm shown on the electrocardiogram strip below. The nurse identifi es this rhythm as which of the following?
- A. Atrial fi brillation
- B. Ventricular tachycardia.
- C. Premature ventricular contractions (PVCs).
- D. Third-degree heart block.
Correct Answer: C
Rationale: PVCs are early depolarizations originating in the ventricles, and they present exactly as seen in your strip.
The client with a major burn injury receives total parenteral nutrition (TPN). The expected outcome is to:
- A. Correct water and electrolyte imbalances.
- B. Allow the gastrointestinal tract to rest.
- C. Provide supplemental vitamins and minerals.
- D. Ensure adequate caloric and protein intake.
Correct Answer: D
Rationale: Major burn injuries significantly increase metabolic demands, requiring high caloric and protein intake to support healing and tissue repair. TPN is primarily used to meet these nutritional needs when oral or enteral feeding is not feasible.
The following scenario applies to the next 1 items
The nurse has received prescriptions for a newborn infant in the postpartum unit.
Item 1 of 1
Orders
1958:
• phytonadione 1 mg intramuscular (IM) x 1 dose
• erythromycin ophthalmic ointment 0.5% apply from unit dose (1 cm) to both eyes
The nurse administers the prescribed medications.
The nurse should administer the phytonadione using ............ The nurse will inject the medication.............................It would be appropriate for the nurse to ...................... The nurse understands that the purpose of administering newborn erythromycin ophthalmic ointment is ............................. The nurse should apply this ointment to the ......................... Once the ointment is administered, the nurse should ..........................
- A. ¾-in, 25-gauge needle.
- B. into the middle third of the anterolateral aspect of the thigh.
- C. aspirate before injecting the medication.
- D. massage the area to promote medication absorption.
- E. prevent ophthalmia neonatorum caused by Neisseria gonorrhoeae.
- F. lower conjunctival sac.
- G. wipe the ointment from the outer eye after one minute.
Correct Answer: A,B,D,E,F
Rationale: Phytonadione is administered with a 25-gauge, ¾-in needle in the vastus lateralis; erythromycin prevents ophthalmia neonatorum and is applied to the lower conjunctival sac without wiping.
A client with osteoporosis is prescribed alendronate (Fosamax). Which instruction should the nurse include?
- A. Take the medication at bedtime.
- B. Remain upright for 30 minutes after taking.
- C. Crush the tablet for easier swallowing.
- D. Take with a full meal.
Correct Answer: B
Rationale: Remaining upright for 30 minutes after taking alendronate prevents esophageal irritation.
The nurse is assessing a client for neurologic impairment after a total hip replacement. Which of the following would indicate impairment in the affected extremity?
- A. Decreased distal pulse.
- B. Inability to move.
- C. Diminished capillary refill.
- D. Coolness to the touch.
Correct Answer: B
Rationale: Inability to move suggests nerve damage, a serious complication requiring immediate evaluation.
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