A nurse is assessing a client who is receiving intravenous therapy. The nurse should identify which of the following findings as a manifestation of fluid volume excess? a. Decreased bowel sounds b. Distended neck veins c. Bilateral muscle weakness d.Thread pulse✅✅✅ b. Distended neck veins
A nurse is caring for a client who has hyponatremia and is receiving an infusion of a prescribed hypertonic solution. Which of the following findings should indicate to the nurse that the treatment is effective? a. Absent Chvostek’s sign b. Improved cognition c. Decreased vomiting d. Cardiac arrhythmias absent✅✅✅ b. Improved cognition
A nurse is teaching a client who has a new prescription for a nitroglycerin transdermal patch. Which of the following instructions should the nurse include? a. “Discontinue the patch if you experience a headache.” b. “Apply a new patch if you have chest pain.” 1 / 4 2 / 22 c. “Cover the patch with dry gauze when taking a shower.” d. “Remove the patch prior to going to bed.”✅✅✅ d. “Remove the patch prior to going to bed.”
A nurse is reviewing he laboratory results of a client who has a prescrip- tion for sodium polystyrene sulfonate (Kayexalate) every 6 hr. which of the following should the nurse report to the provider? a. Creatinine 0.72 mg/dL b. Sodium 138 mEq/L c. Magnesium 2 mEq/L d. Potassium 5.2 mEq/L✅✅✅ d. Potassium 5.2 mEq/L – Hyperkalemia (serum potas- sium level greater than 5.0 mEq/L) increases the client risk for fatal cardiac dysrhythmias. Kayexalate is used to decrease the serum potassium level so the PN should monitor the client’s serum potassium level
A nurse is caring for a client who has tuberculosis and is taking isoniazid and rifampin. Which of the following outcomes indicates that the client is adhering to the medication regimen? a.The client has a negative sputum culture b.The client tests negative for HIV c.The client has a positive purified protein derivative test 2 / 4 3 / 22 d.The client’s liver function test results are within the expected reference range✅✅✅ a. The client has a negative sputum culture
A client is caring for a client who develops an anaphylactic reaction to IV administration. After assessing the client’s respiratory status and stopping the medication infusion. Which of the following actions should the nurse take next? a. Replace the infusion with 0.9% sodium chloride b. Give diphenhydramine IM c. Elevate the client’s legs and feet d. Administer epinephrine IM✅✅✅ d. Administer epinephrine IM
A nurse is caring for a client who is taking sertraline and reports a desire to begin taking supplements. Which of the following supplements should the nurse advise the client to avoid? a. St. John’s Wort b. Ginger root c. Black cohosh d. Coenzyme Q10✅✅✅ a. St. John’s Wort
A nurse is caring for a client who has heart failure and a new prescription for lisinopril. For which of the following adverse effects should the nurse monitor when administering lisinopril? a. Bradycardia 3 / 4 4 / 22 b. Hypokalemia c.Tinnitus d. Hypotension✅✅✅ d. Hypotension
A nurse is assessing a client who is receiving heparin IV continuous IV. The client has an PPT of 90 seconds. They should monitor the client for which of the following changes in their vital signs? a. Decreased temperature b. Increased pulse rate c. Decreased respiratory rate d. Increased blood pressure✅✅✅ d. Increased blood pressure
