Nokea
The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension. The nurse should:
- A. Question the order
- B. Administer the medications
- C. Administer separately
- D. Contact the pharmacy
Correct Answer: B
Rationale: Lisinopril and furosemide are commonly used together for hypertension, as they have complementary effects, so administering them is appropriate.
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The nurse is obtaining a history on a 74-year-old client. Which statement made by the client would alert the nurse to a possible fluid and electrolyte imbalance?
- A. My skin is always so dry.'
- B. I often use a laxative for constipation.'
- C. I have always liked to drink a lot of water.'
- D. I sometimes have a problem with dribbling urine.'
Correct Answer: B
Rationale: Frequent laxative use can cause fluid and electrolyte losses (e.g., potassium, sodium), leading to imbalances, unlike the other statements.
A client with a T5 spinal cord injury suddenly begins sweating profusely in the face and neck. Vital signs reveal sudden bradycardia and significant increase in blood pressure. Which is the priority nursing action?
- A. administer nitrate or nifedipine
- B. check the client for fecal impaction
- C. check the client for bladder distention
- D. place the bed in high Fowler's position
Correct Answer: C
Rationale: These symptoms indicate autonomic dysreflexia, often triggered by bladder distention in spinal cord injuries above T6. Checking and relieving bladder distention is the priority.
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.
The nurse is assessing the laboratory results of a client scheduled to receive phenytoin (Dilantin). The Dilantin level, drawn 2 hours ago, is 30 mcg/mL. What is the appropriate nursing action?
- A. Administer the Dilantin as scheduled
- B. Hold the scheduled dose and notify the physician
- C. Decrease the dosage from 100 mg to 50 mg
- D. Increase the dosage to 200 mg from 100 mg
Correct Answer: B
Rationale: A Dilantin level of 30 mcg/mL is above the therapeutic range (10-20 mcg/mL), indicating toxicity risk. The nurse should hold the dose and notify the physician for further orders.
The nurse is preparing to discharge a client diagnosed with gout. Which statement by the client indicates understanding of dietary restrictions while managing gout?
- A. I should avoid beer, anchovies, and liver.
- B. I should avoid bananas, grapefruit, and oranges.
- C. I should avoid dairy products such as milk and ice cream.
- D. I should avoid red wine, dark chocolate, and aged cheeses.
Correct Answer: A
Rationale: Beer, anchovies, and liver are high in purines, which can exacerbate gout, making avoidance appropriate.