The physician has ordered DDAVP (desmopressin acetate) for a client with diabetes insipidus. Which finding indicates that the medication is having its intended effect?
- A. The client's appetite has improved.
- B. The client's morning blood sugar was 120 mg/dL.
- C. The client's urinary output has decreased.
- D. The client's activity level has increased.
Correct Answer: C
Rationale: DDAVP reduces excessive urination in diabetes insipidus by mimicking antidiuretic hormone, decreasing urinary output. Appetite, blood sugar, and activity are not directly affected.
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Which finding in the patient's history contraindicates the use of Imitrex (sumatriptan) for the prevention of migraine headaches?
- A. Diabetes
- B. Angina
- C. Renal calculi
- D. Peptic ulcer disease
Correct Answer: B
Rationale: Sumatriptan (Imitrex) is a vasoconstrictor contraindicated in patients with angina due to the risk of coronary artery vasoconstriction and ischemia. Diabetes renal calculi and peptic ulcer disease are not contraindications for sumatriptan.
The nurse is caring for a client with a spinal cord injury at C5. Which complication is the client at greatest risk for?
- A. Respiratory depression
- B. Autonomic dysreflexia
- C. Pressure ulcers
- D. Deep vein thrombosis
Correct Answer: A
Rationale: A C5 spinal cord injury impairs diaphragm function (innervated by C3–C5), placing the client at greatest risk for respiratory depression due to weak respiratory muscles. The other complications are risks but less immediate.
A physician's order reads: Administer furosemide oral solution 0.5 mL stat. The furosemide bottle dosage is 10 mg/mL. What dosage of furosemide should the nurse give to this infant?
- A. 5 mg
- B. 0.5 mg
- C. 0.05 mg
- D. 20 mg
Correct Answer: A
Rationale: 1 mg = 0.1 mL, then 0.5 mL X = 5 mg.
The nurse is caring for a client with a chest tube. Which observation requires immediate intervention?
- A. The water seal chamber is bubbling continuously.
- B. The drainage system is positioned below the client’s chest.
- C. The chest tube is taped securely to the chest.
- D. The client is lying on the affected side.
Correct Answer: D
Rationale: Lying on the affected side can compress the chest tube, obstructing drainage and risking pneumothorax or tension pneumothorax, requiring immediate repositioning. Continuous bubbling in the water seal is expected initially, and the other findings are appropriate.
When a client is receiving vasoactive therapy IV, such as dopamine (Intropin), and extravasation occurs, the nurse should be prepared to administer which of the following medications directly into the site?
- A. Phentolamine (Regitine)
- B. Epinephrine
- C. Phenylephrine (Neo-Synephrine)
- D. Sodium bicarbonate
Correct Answer: A
Rationale: Phentolamine is given to counteract the-adrenergic effects that cause ischemia and necrosis of local tissue. Epinephrine is an endogenous catecholamine that produces vasoconstriction and increases heart rate and contractility. Phenylephrine causes constriction of arterioles of skin, mucous membranes, and viscera, which in turn can cause ischemia and necrosis. Sodium bicarbonate is an alkalinizing agent that is incompatible with dopamine.
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