Nokea
The nurse administers prescribed pancreatin replacement therapy to Bonnie.
To effectively evaluate the effect of this treatment, should expect that this medication will result to
- A. Bulky, foul, smelly stools.
- B. Close to normal stools.
- C. Loose, frequent stools.
- D. Constipation.
Correct Answer: B
Rationale: Pancreatin aids fat digestion, resulting in near-normal stools in pancreatic insufficiency.
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The client's blood gas values are: pH=7.35; CO2=60; HCO3=34; and pO2=60. The nurse correctly interprets these to indicate that the client is in which state?
- A. Compensated respiratory acidosis
- B. Partly compensated metabolic alkalosis
- C. Metabolic alkalosis
- D. Metabolic acidosis
Correct Answer: A
Rationale: Normal pH with elevated CO2 and HCO3 indicates compensated respiratory acidosis, where kidneys retain bicarbonate to balance chronic CO2 retention.
The nurse is administering terbutaline (Brethine) to a client in labor. Prior to administration of the medication, the nurse assesses the client's pulse to be 144. The nurse's priority action should be to
- A. withhold the medication.
- B. decrease the dose by half.
- C. administer the medication.
- D. wait 15 minutes, then recheck the rate.
Correct Answer: A
Rationale: Terbutaline, a tocolytic, can cause maternal tachycardia. A pulse of 144 indicates significant tachycardia, a side effect requiring the medication to be withheld to prevent further cardiovascular strain. Decreasing the dose (B) is not within nursing scope, administering (C) ignores the risk, and waiting (D) delays intervention.
The nurse is preparing to perform a physical examination on an 8 month-old who is sitting contentedly on his mother's lap. Which of the following should the nurse do first?
- A. Elicit reflexes
- B. Measure height and weight
- C. Auscultate heart and lungs
- D. Examine the ears
Correct Answer: C
Rationale: Auscultate heart and lungs. Performing this during a quiet moment ensures clear sound detection.
A nurse is administering blood to a patient who has a low hemoglobin count.
The patient asks how long the RBC last in the body? The correct response is:
- A. The life span of RBC is 45 days.
- B. The life span of RBC is 60 days.
- C. The life span of RBC is 90 days.
- D. The life span of RBC is 120 days.
Correct Answer: D
Rationale: Red blood cells have a lifespan of approximately 120 days.
An 82-year-old woman who has Alzheimer's disease is admitted to the acute care unit. She frequently gets out of bed and wanders in the hall, unable to find her way back to her room. She even gets in the beds of other clients. What nursing action is most appropriate for this client?
- A. Restrain her so she will not wander in the halls
- B. Ask her roommate to call the nurse whenever she leaves the room
- C. Punish her when she gets in a bed other than her own
- D. Put her favorite picture on the door to her room
Correct Answer: D
Rationale: A familiar picture on the door helps the Alzheimer's client recognize her room, reducing wandering safely. Restraints, roommate monitoring, or punishment are inappropriate or ineffective.