Nokea
A client is admitted with the following symptoms: dependent pitting edema, abdominal distention, and a recent 10-lb weight gain. The client has received 80 mg of furosemide (Lasix).
Which of the following nursing observations is MOST important to report to the next shift?
- A. Complaints of nausea and vomiting.
- B. Urine output of 200 cc in 2 hours.
- C. Quiet and withdrawn behavior after lunch.
- D. Blood pressure changes from 160/90 to 150/90.
Correct Answer: B
Rationale: Strategy: The topic of the question is unstated. Read the answers for clues. (1) further signs and symptoms of right-sided heart failure; not a priority (2) correct-furosemide is diuretic, which warrants close observation of the client's urine output (3) further signs and symptoms of right-sided heart failure; not a priority (4) may occur as a result of volume loss, but is not a priority over answer choice #2
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The nurse is to administer the daily dose of digoxin to an adult client. What is it essential for the nurse to do before administering the medication?
- A. Check the client's temperature
- B. Check the client's blood pressure
- C. Check the client's respirations
- D. Check the client's apical pulse
Correct Answer: D
Rationale: Digoxin slows heart rate; checking the apical pulse ensures it's above 60 bpm to avoid bradycardia. Temperature, blood pressure, and respirations are less critical.
The doctor has ordered chlorpromazine (Thorazine) to control an alcoholic client's restlessness, agitation, and irritability following surgery. The nurse should check the order with the doctor based on which of the following rationales?
- A. The nurse believes that the client's symptoms reflect alcohol withdrawal.
- B. The nurse does not know if the client is allergic to this medication.
- C. The nurse knows that the client is not psychotic.
- D. The nurse routinely checks on the doctor's orders.
Correct Answer: A
Rationale: medication is contraindicated for the treatment of alcohol withdrawal symptoms; medication will lower client's seizure threshold and BP, causing potentially serious medical consequences
An adult is thought to have myasthenia gravis. The nurse knows that which test is most likely to be ordered for the client?
- A. Lumbar puncture
- B. CT scan
- C. Cerebral angiogram
- D. Edrophonium (Tensilon) test
Correct Answer: D
Rationale: The edrophonium test, which temporarily improves muscle strength in myasthenia gravis, confirms diagnosis by enhancing neuromuscular transmission, unlike imaging or lumbar puncture.
The physician has ordered insertion of a nasogastric tube to provide supplemental feedings for a client recovering from a stroke. To facilitate insertion of the nasogastric tube, the nurse should:
- A. Offer the client ice chips to swallow as the tube is advanced.
- B. Tell the client to flex his neck on his chest.
- C. Tell the client to hyperextend his neck.
- D. Place the tube in warm water.
Correct Answer: B
Rationale: Flexing the neck aligns the esophagus, facilitating nasogastric tube insertion. Ice chips increase choking risk. Hyperextension misaligns the airway. Warm water is ineffective.
Delirium tremens could best be described as
- A. Disorganized thinking, feelings of terror and non-purposeful behavior
- B. A generalized shaking of the body accompanied by repetitive thoughts
- C. An excited state accompanied by disorientation, hallucination and tachycardia
- D. Single or multiple jerks caused by rapid contracting muscles
Correct Answer: C
Rationale: An excited state accompanied by disorientation, hallucination and tachycardia. Delirium tremens involves severe withdrawal symptoms, including confusion, hallucinations, and autonomic hyperactivity.