Nokea
The nurse knows that the MOST reliable client measure for evaluating the desired response diuretic therapy is to
- A. obtain daily weights.
- B. obtain urinalysis.
- C. monitor Na⺠and K⺠levels.
- D. measure intake.
Correct Answer: A
Rationale: effectiveness of diuretic therapy is demonstrated by decreased edema and is measured by daily weights
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The nurse is teaching a client with a new diagnosis of epilepsy about valproic acid (Depakote). Which of the following instructions should the nurse include?
- A. Take the medication with grapefruit juice.
- B. Report any bruising or bleeding.
- C. Stop the medication if seizures decrease.
- D. Avoid regular liver function Test s.
Correct Answer: B
Rationale: Valproic acid can cause thrombocytopenia; reporting bruising or bleeding is critical. Options A, C, and D are incorrect or unsafe.
A man who has diabetes complains of hunger; is pale, shaky, and perspiring; and has cool skin. What is the most appropriate initial action for the nurse?
- A. Call the physician for orders
- B. Give the client cola to drink
- C. Have the client lie down
- D. Administer the next dose of insulin
Correct Answer: B
Rationale: Symptoms indicate hypoglycemia; giving cola provides quick glucose to raise blood sugar. Calling the physician, lying down, or giving insulin delays or worsens the situation.
Which of these parents' comments about a newborn would most likely reveal an initial finding of a suspected pyloric stenosis?
- A. I noticed a little lump a little above the belly button.
- B. The baby seems hungry all the time.
- C. Mild vomiting turned into vomiting that shot across the room.
- D. We notice irritation and spitting up immediately after feedings.
Correct Answer: C
Rationale: Mild vomiting turned into vomiting that shot across the room. Projectile vomiting is a hallmark of pyloric stenosis.
An infant with a positive PKU blood Test .
The nurse knows that which of the following plans would be a priority for an infant with a positive PKU blood Test ?
- A. Place the infant on Lofenlac formula.
- B. Administer medium-chain triglyceride (MCT) oil with each feeding.
- C. Provide genetic counseling for the family.
- D. Place the infant on Lorenzo's Oil treatments.
Correct Answer: A
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-Guthrie blood Test evaluates neonate for phenylketonuria (PKU); Lofenalac formula is low in phenylalanine, but contains minerals and vitamins to provide a balanced nutritional formula (2) could be a plan for a child with cystic fibrosis (3) important, but is not as high a priority as answer choice #1 (4) would be a plan of care for a child with adrenoleukodystrophy (ALD)
A client has been taking propranolol (Inderal) 40 mg bid and furosemide (Lasix) 40 mg qd for several months. Two weeks ago, the physician added verapamil (Calan) 80 mg tid to his medication regimen.
It is MOST important for the nurse to assess for which of the following?
- A. Tachycardia.
- B. Diarrhea.
- C. Peripheral edema.
- D. Impotence.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to medication. (1) will cause bradycardia (2) usually causes constipation (3) correct-Calan is a calcium-channel blocker, depresses myocardial contractility, decreases work of ventricles and O2 demand, dilates coronary arteries, when used with other antihypertensives can cause hypotension and heart failure (4) not most important or frequent side effect