Nursing Elites

1. A nurse is caring for a client who has cirrhosis and a new prescription for lactulose. The nurse should monitor the client for which of the following therapeutic effects of this medication?

• A. Improved mental status.
• B. Increased urine output.
• C. Decreased serum ammonia.
• D. Decreased bilirubin levels.

Correct answer: C

Rationale: The correct answer is C: Decreased serum ammonia. Lactulose is prescribed to decrease serum ammonia levels in clients with cirrhosis and hepatic encephalopathy. By reducing serum ammonia, lactulose helps improve the mental status of these clients. Therefore, monitoring for decreased serum ammonia is crucial to assess the effectiveness of lactulose therapy. Choice A (Improved mental status) is indirectly related as it is the desired outcome of decreasing ammonia levels. Choices B (Increased urine output) and D (Decreased bilirubin levels) are not directly associated with the therapeutic effects of lactulose in cirrhosis and hepatic encephalopathy.

2. Which electrolyte imbalance should be closely monitored in patients on diuretics?

• A. Hypokalemia
• B. Hyponatremia
• C. Hyperkalemia
• D. Hypercalcemia

Correct answer: A

Rationale: The correct answer is A: Hypokalemia. Patients on diuretics are at risk of developing hypokalemia due to increased potassium excretion by the kidneys. Hypokalemia can lead to serious consequences such as cardiac arrhythmias. Hyponatremia (choice B) is an imbalance of sodium levels and is not typically associated with diuretic use. Hyperkalemia (choice C) is the opposite condition where potassium levels are elevated and is less common in patients on diuretics. Hypercalcemia (choice D) is an excess of calcium in the blood and is not directly related to diuretic use. Therefore, monitoring for hypokalemia is crucial in patients taking diuretics.

3. What is the first intervention for a patient experiencing anaphylactic shock?

• A. Administer epinephrine
• B. Administer corticosteroids
• C. Administer antihistamines
• D. Administer oxygen

Correct answer: A

Rationale: The correct answer is to administer epinephrine as the first intervention for a patient experiencing anaphylactic shock. Epinephrine is crucial in reversing the allergic reaction and restoring cardiovascular stability. Corticosteroids (Choice B) are not the first-line treatment for anaphylactic shock but may be used as an adjunct therapy. Antihistamines (Choice C) can help relieve itching and hives but are not as effective as epinephrine in treating the systemic effects of anaphylaxis. Oxygen (Choice D) may be necessary to support breathing in severe cases of anaphylaxis, but administering epinephrine takes precedence in the management of anaphylactic shock.

4. A client in active labor requests pain management. Which of the following actions should the nurse take?

• A. Administer ondansetron.
• B. Place the client in a warm shower.
• C. Apply fundal pressure during contractions.
• D. Assist the client to a supine position.

Correct answer: B

Rationale: During active labor, nonpharmacologic comfort measures like placing the client in a warm shower are effective for pain relief. Ondansetron (Choice A) is an antiemetic and not used for pain management during labor. Applying fundal pressure (Choice C) can cause harm and is not recommended due to the risk of uterine rupture. Assisting the client to a supine position (Choice D) is not ideal in labor as it can decrease blood flow to the placenta and is associated with increased maternal complications.

5. What is the priority nursing intervention for a patient with hyperkalemia?

• A. Administer calcium gluconate
• B. Administer insulin
• C. Administer sodium bicarbonate
• D. Administer a diuretic

Correct answer: A

Rationale: The correct answer is to administer calcium gluconate. In hyperkalemia, the priority is to protect the heart from potential complications like arrhythmias. Calcium gluconate is the first-line treatment as it stabilizes the cardiac cell membrane. Insulin (Choice B) and sodium bicarbonate (Choice C) can be used in conjunction with other treatments to shift potassium into cells, but calcium gluconate is the priority. Administering a diuretic (Choice D) is not the primary intervention for hyperkalemia and can even worsen the condition by reducing potassium excretion.

Similar Questions