Nokea
What precaution should a nurse take to minimize the risk of death when using potassium chloride to flush a lock or central venous catheter?
- A. Use a dilute form of potassium chloride before flushing locks.
- B. Warm the potassium chloride before flushing locks.
- C. Document on the client’s chart.
- D. Ask the client to implement the instruction.
Correct Answer: A
Rationale: The correct answer is A because concentrated potassium chloride can cause cardiac arrest if injected rapidly.
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Before administering a benzodiazepine, what should the nurse assess?
- A. Sleep problems
- B. Memory impairment
- C. Cognitive disorder
- D. Behavior changes
Correct Answer: D
Rationale: Behavioral changes may indicate underlying issues or contraindications for benzodiazepines.
Which statements are correct for lithium?
- A. Effective for all
- B. Has a delay of 10 to 28 days in achieving therapeutic benefits
- C. Has a narrow range of safety between a therapeutic serum level and toxic levels
- D. May be therapeutic when administered in combination with any other drugs
Correct Answer: C
Rationale: Lithium has a narrow therapeutic window, requiring careful monitoring to prevent toxicity.
What does weight gain during the postoperative period indicate?
- A. Urine retention
- B. Healthy recovery
- C. Paralytic ileus
- D. Hypoxia
Correct Answer: C
Rationale: The correct answer is C because weight gain can indicate fluid retention due to paralytic ileus.
What does the nurse give priority to assessing immediately following Mr. Singer’s total laryngectomy?
- A. Elimination patterns
- B. Level of pain
- C. Gag reflex
- D. Respiratory status
Correct Answer: D
Rationale: Respiratory status is critical due to the altered airway anatomy.
During the rehabilitative phase following his cerebrovascular accident, Mr. K. is taught measures to relieve or prevent constipation. Which of these statements indicates that Mr. K. needs further health teaching?
- A. I eat whole-wheat bread with my meals.'
- B. I eat fruit three times a day.'
- C. I don't drink fluids after 4 P.M.'
- D. I don't like to take enemas.'
Correct Answer: C
Rationale: Restricting fluid intake after 4 P.M. can contribute to dehydration and constipation, making this statement indicative of the need for further education on proper hydration practices.