Nokea
A client receiving oxygen at 6 L/min.
What information concerning the patient is MOST important for the nurse to document on the lab slip that accompanies the blood sample?
- A. The patient's position in bed and the respiratory rate.
- B. The site used to obtain the blood specimen.
- C. The use of supplemental oxygen.
- D. The patient's diagnosis and blood type.
Correct Answer: C
Rationale: Strategy: Think about each answer choice and how it relates to blood gases. (1) unnecessary to document positioning (2) unnecessary to document site used (3) correct-necessary for accurate Test results (4) unnecessary to document blood type, should document diagnosis
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The nurse is teaching a client with a new diagnosis of gout about dietary modifications. Which of the following foods should the nurse advise the client to avoid?
- A. Fresh spinach.
- B. Lean chicken breast.
- C. Canned sardines.
- D. Whole-grain pasta.
Correct Answer: C
Rationale: Canned sardines are high in purines, which increase uric acid levels and exacerbate gout. Options A, B, and D are suitable: spinach is low-purine, chicken is lean, and whole-grain pasta is not restricted.
The nurse is administering terbutaline (Brethine) to a client in labor.
- A. What is the priority action for the nurse if the client’s pulse is 144 before administering terbutaline?
- B. Withhold the medication.
- C. Decrease the dose by half.
- D. Administer the medication.
- E. Wait 15 minutes, then recheck the rate.
Correct Answer: A
Rationale: Terbutaline causes maternal tachycardia, and a pulse of 144 indicates a significant side effect. Withholding the medication is the priority to prevent further complications like pulmonary edema. Reducing the dose, administering, or delaying without action is unsafe.
A client is to begin taking Fosamax. The nurse must emphasize which of these instructions to the client when taking this medication? 'Take Fosamax
- A. on an empty stomach.'
- B. after meals.'
- C. with calcium.'
- D. with milk 2 hours after meals.'
Correct Answer: A
Rationale: Fosamax should be taken first thing in the morning with 6-8 ounces of plain water at least 30 minutes before other medication or food. Food and fluids (other than water) greatly decrease the absorption of Fosamax. The client must be instructed to remain in the upright position for 30 minutes following the dose to facilitate passage into the stomach and minimize irritation of the esophagus.
The client with cancer has an order for Adriamycin. Which of the following untoward effects is of particular concern to the nurse?
- A. Alopecia
- B. Fatigue
- C. Dysrhythmias
- D. Nausea
Correct Answer: C
Rationale: Adriamycin (doxorubicin) is cardiotoxic, and dysrhythmias are a serious concern. Alopecia, fatigue, and nausea are common but less life-threatening.
A client who is diagnosed with cystitis has been given a prescription for phenazopyridine (Pyridium). She asks the nurse why she has been given this medication. What should the nurse reply?
- A. Pyridium is an antibiotic that will kill the bacteria causing your infection.'
- B. Pyridium is an analgesic that will make you less aware of the pain and discomfort.'
- C. Pyridium is a urinary tract anesthetic that will kill the pain until the antibiotics have had time to work.'
- D. Pyridium will help to prevent kidney damage from the bladder infection.'
Correct Answer: C
Rationale: Phenazopyridine is a urinary tract anesthetic, relieving pain and burning during urination until antibiotics resolve cystitis. It's not an antibiotic, analgesic, or kidney protectant.