Nokea
The physician has ordered intravenous fluid with potassium for a client admitted with gastroenteritis and dehydration. Before adding potassium to the intravenous fluid, the nurse should:
- A. Assess the urinary output
- B. Obtain arterial blood gases
- C. Perform a dextrostick
- D. Obtain a stool culture
Correct Answer: A
Rationale: Adequate urinary output (at least 30 mL/hr) must be confirmed before adding potassium to IV fluids to prevent hyperkalemia.
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A client with osteomylitis has an order for a trough level to be done because he is taking Gentamycin. When should the nurse call the lab to obtain the trough level?
- A. Before the first dose
- B. 30 minutes before the fourth dose
- C. 30 minutes after the first dose
- D. 30 minutes before the first dose
Correct Answer: B
Rationale: Trough levels measure the lowest drug concentration and are drawn just before a dose after steady-state, typically around the fourth dose for Gentamicin.
The nurse is caring for a client with B-Thalassemia major. Which therapy is used to treat Thalassemia?
- A. IV fluids
- B. Frequent blood transfusions
- C. Oxygen therapy
- D. Iron therapy
Correct Answer: B
Rationale: Frequent transfusions manage severe anemia in B-Thalassemia major.
The nurse is precepting a student nurse on an orthopedic floor. The student nurse needs to insert an indwelling catheter into a male client. Which of the following statements by the student nurse are correct regarding insertion of the catheter? Select all that apply.
- A. I need to establish an aseptic field.
- B. I will place the client in the supine position.
- C. I will lubricate the tip of the catheter with sterile lubricant included in the tray.
- D. I will inflate the catheter balloon with 5 cc of sterile water.
Correct Answer: A,B,C
Rationale: Aseptic technique, supine positioning, and sterile lubrication are correct for catheter insertion. Inflating the balloon with 5 cc is incorrect, as most catheters require 10 cc of sterile water for balloon inflation.
The nurse is caring for a client taking levothyroxine (Synthroid) for hypothyroidism. Which finding indicates a side effect of this medication?
- A. weight loss
- B. weight gain
- C. light sensitivity
- D. excessive sleepiness
Correct Answer: A
Rationale: Weight loss can indicate excessive levothyroxine dosing, as it increases metabolism, unlike the other options, which are not typical side effects.
The nurse is caring for a client following a crushing injury to the chest. Which finding would be most indicative of a tension pneumothorax?
- A. Frothy hemoptysis
- B. Trachea shift toward the unaffected side of the chest
- C. Subcutaneous emphysema noted at the anterior chest
- D. Opening chest wound with a whistle sound emitting from the area
Correct Answer: B
Rationale: Tension pneumothorax causes a mediastinal shift, including tracheal deviation toward the unaffected side due to increased intrathoracic pressure.