Nokea
What should the nurse monitor in a client receiving baclofen?
- A. Blood pressure.
- B. Spasticity levels.
- C. Blood glucose.
- D. Respiratory rate.
Correct Answer: B
Rationale: Spasticity levels are monitored to evaluate the effectiveness of baclofen in reducing muscle spasticity.
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The nurse is assessing a client with cirrhosis who has developed hepatic encephalopathy. The nurse should notify the physician of a decrease in which lab serum that is a potential precipitating factor for hepatic encephalopathy?
- A. Aldosterone.
- B. Creatinine.
- C. Potassium.
- D. Protein.
Correct Answer: C
Rationale: Hypokalemia (C) can precipitate hepatic encephalopathy by increasing ammonia production. Aldosterone (A), creatinine (B), and protein (D) are less directly related.
The client has a latex allergy. What should the nurse teach the client to do before having surgery at a free-standing surgery center? Select all that apply.
- A. Determine that there will be a latex-safe environment for surgery.
- B. Report symptoms experienced with the latex allergy (e.g., rhinitis, conjunctivitis, flushing).
- C. Notify the health care providers at the surgery center.
- D. Wear a stainless steel medical alert bracelet into the surgical suite.
- E. Ask to have the surgery at a hospital.
Correct Answer: A,B,C
Rationale: Treatment and diagnostic evaluation must be done in a latex-safe environment. Signs/symptoms may be mild to anaphylaxis. Clients with latex allergy are advised to notify their health care providers and to wear a medical ID; however, all metal and jewelry must be removed prior to surgery as they could conduct an electrical current.
In the oliguric phase of acute renal failure, the nurse should assess the client for:
- A. Pulmonary edema.
- B. Metabolic alkalosis.
- C. Hypotension.
- D. Hypokalemia.
Correct Answer: A
Rationale: Pulmonary edema is a risk in the oliguric phase due to fluid overload from reduced urine output.
The nurse should be especially alert for signs and symptoms of digoxin toxicity if serum levels indicate that the client has a:
- A. Low sodium level.
- B. High glucose level.
- C. High calcium level.
- D. Low potassium level.
Correct Answer: D
Rationale: Low potassium (hypokalemia) increases the risk of digoxin toxicity by enhancing digoxin's binding to cardiac cells, leading to arrhythmias.
The nurse is assessing a client with a recent history of an above-the-knee amputation presenting with phantom limb pain. The nurse anticipates a prescription for
- A. aripiprazole
- B. oxycodone
- C. amitriptyline
- D. hydroxyzine
Correct Answer: C
Rationale: Amitriptyline, a tricyclic antidepressant, is commonly used for neuropathic pain, including phantom limb pain, due to its effects on nerve signaling.