Nokea
The physician has prescribed hydralazine (Apresoline) for a client with acute glomerulonephritis. Which finding indicates that the drug is having the desired effect?
- A. The client's appetite has improved.
- B. Creatinine levels have returned to normal.
- C. The client's blood pressure has decreased.
- D. Urinary output is amber in color.
Correct Answer: C
Rationale: Apresoline (hydralazine) is an antihypertensive; therefore, a decrease in blood pressure indicates the medication is working. Answers A, B, and D indicate that the overall condition of the client is improving, but they are not the result of the medication.
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The nurse is to remove an indwelling urinary catheter from an adult client. Which step should be done first?
- A. Cut the catheter with scissors.
- B. Withdraw the fluid from the balloon.
- C. Clamp the catheter.
- D. Remove the catheter.
Correct Answer: B
Rationale: Withdrawing fluid from the balloon deflates it, allowing safe catheter removal without urethral trauma. Cutting, clamping, or pulling without deflation risks injury.
The nurse is caring for a client with a suspected stroke. Which of the following actions should the nurse perform FIRST?
- A. Administer aspirin 325 mg PO.
- B. Obtain a CT scan of the head.
- C. Check the client’s blood glucose level.
- D. Start an IV line.
Correct Answer: C
Rationale: Hypoglycemia can mimic stroke symptoms; checking blood glucose is the first step to rule out treatable causes. Options A, B, and D are secondary.
The nurse is caring for clients in the diabetic clinic.
Which of the following clients should the nurse see FIRST?
- A. A client with sunken eyeballs and a fruity breath odor.
- B. A client who complains of pain in his calves when he exercises.
- C. A client who states that she drinking liquids frequently and is always hungry.
- D. A client says that she is having difficulty sleeping and cries frequently.
Correct Answer: A
Rationale: Strategy: Determine the least stable client. (1) correct-indicates diabetic ketoacidosis; treat with normal saline and regular insulin (2) suggestive of intermittent claudication, not an emergency situation (3) suggestive of hyperglycemia, should assess blood sugar (4) psychosocial issues, physical takes priority
A client with a reactive depression has the greaTest chance of success in activities that require psychic and physical energy if the nurse schedules activities in the
- A. morning hours.
- B. middle of the day.
- C. afternoon hours.
- D. evening hours.
Correct Answer: A
Rationale: client with reactive depression has the highest level of physical and psychic energy in the morning
A patient with type I diabetes mellitus (IDDM) asks the nurse why the doctor ordered human insulin instead of beef or pork insulin. Which of the following responses by the nurse is BEST?
- A. Human insulin is less likely to cause you to have a localized allergic reaction to the injection.'
- B. Human insulin will cause you to experience fewer problems with hypoglycemia or hyperglycemia.'
- C. Human insulin prevents the development of long-term damage to the eyes and kidneys.'
- D. Human insulin does not cause the formation of antibodies because the protein structure is identical to your own.'
Correct Answer: D
Rationale: protein molecules are identical with human insulin