1. A nurse is assessing a client who is 12hr postoperative following a colon resection. Which of the following findings should the nurse report to the
... [Show More] surgeon?
a. Heart rate 90/min
b. Absent bowel sounds
c. Hgb 8.2 g/dl
d. Gastric pH of 3.0
- c. Hgb 8.2 g/dl
Rationale: Normal Hgb is 13-18M g/dl, 12-16 g/dl. This may indicate a possible haemorrhaging.
2. A nurse is caring for a client who has diabetes insipidus. Which of the following medications should the nurse plan to administer?
a. Desmopressin
b. Regular insulin
c. Furosemide
d. Lithium carbonate
- a. Desmopressin
Rationale: Diabetes Insipidus has decreased ADH. Administer Desmopressin/Vasopressin increase ADH
and to stop patient on urinating.
3. A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several times daily for 3 years. Which of the following test should the nurse monitor?
a. Fasting blood glucose
b. Stool for occult blood - GI bleed
c. Urine for white blood cells
d. Serum calcium
- b. Stool for occult blood - GI bleed
Rationale: ATI Pharm 16. Pg. 485 Ibuprofen (NSAIDs) monitor for GI bleed (bloody, tarry
stools, abdominal pain).
4. A nurse in the emergency department is assessing a client. Which of the following actions should the nurse take first (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)
a. Obtain a sputum sample for culture
b. Prepare the client for a chest x-ray
c. Initiate airborne precautions
d. Administer ondansetron.
- c. Initiate airborne precautions
5. A nurse is contacting the provider for a client who has cancer and is experiencing breakthrough pain. Which of the following prescriptions should the nurse anticipate?
a. Transmucosal fentanyl
b. Intramuscular meperidine
c. Oral acetaminophen
d. Intravenous dexamethasone
- a. Transmucosal fentanyl
Rationale: ATI pg. 27 Morphine sulfate and fentanyl are opioid agents used to treat moderate to severe pain. A short-acting pain medication is administered for breakthrough pain.
6. A nurse is admitting a client who reports chest pain and has been placed on a telemetry monitor. Which of the following should the nurse analyze to determine whether the client is experiencing a myocardial infarction?
a. PR interval
b. QRS duration
c. T wave
d. ST segment
- d. ST segment
Rationale: ST elevation indicates MI. ST depression indicates ischemia
7. A nurse is teaching a client who has ovarian cancer about skin care following radiation treatment. Which of the following instructions should the nurse include?
a. Pat the skin on the radiation site to dry it
b. Apply OTC moisturizer to the radiation site
c. Cover the radiation site loosely with a gauze wrap before dressing
d. Use a soft washcloth to clean the area around the radiation site
- a. Pat the skin on the radiation site to dry it
Rationale: pg. 584. Dry the area thoroughly using patting motions.
8. A nurse is caring for a client who is receiving a blood transfusion. The nurse observes that the client has bounding peripheral pulses, hypertension, and distended jugular veins. The nurse should anticipate administering which of the following prescribed medications?
a. Diphenhydramine
b. Acetaminophen
c. Pantoprazole
d. Furosemide
- d. Furosemide
Rationale: S/S may indicate fluid retention or heart failure. It is important to administer diuretics to prevent cardiovascular/respiratory distress.
9. A nurse is assessing a client who is receiving magnesium sulfate IV for the treatment of hypomagnesemia. Which of the following findings indicates effectiveness of the medication?
a. Lungs clear
b. Apical pulse 82/min
c. Hyperactive bowel sounds
d. Blood pressure 90/50 mm Hg
Rationale: pg. 278 Confirmed on answer sheet - b. Apical pulse 82/min
10. A nurse is reviewing a client's ABG results pH 7.42, PaC02 30 mm Hg, and HCO3 21 mEq/L. The nurse should recognize these findings as indication of which of the following conditions?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Compensated respiratory alkalosis
d. Uncompensated respiratory acidosis - c. Compensated respiratory alkalosis
Rationale: because the HCO3 21 trying to compensate for respiratory alkalosis. [Show Less]