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Questions 158

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Question 1 of 5

An expected response to sodium polystyrene sulfonate (Kayexalate) is:

Correct Answer: A

Rationale: Whole blood is the transfusion component of choice when large volumes of blood need to be replaced. Whole blood contains all blood components that are lost during active bleeding.

Question 2 of 5

A 26-year-old male client is brought by his wife to the emergency department (ED) unconscious. Blood is drawn for a stat blood count (CBC), fasting blood sugar level, and electrolytes. An indwelling urinary catheter is inserted. He has a history of type 1 diabetes (insulin-dependent diabetes mellitus [IDDM]). A diagnosis of ketoacidosis is made. Stat lab values reveal a blood sugar level of 520 mg/dL. Which of the following should the nurse expect to administer in the ER?

Correct Answer: C

Rationale: Regular insulin is the fastest acting-insulin; when given IV, it will immediately act to decrease blood sugar. Regular insulin is given to decrease blood glucose levels by promoting metabolism of glucose, inhibiting lipolysis and formation of ketone bodies.

Question 3 of 5

A client with a history of chronic migraines is admitted with complaints of nausea. The nurse should give priority to:

Correct Answer: A

Rationale: Antiemetics relieve nausea in migraines, improving comfort and preventing dehydration.

Question 4 of 5

The nurse who is caring for a client with cancer notes a WBC of 500/mm3 on the laboratory results. Which intervention would be most appropriate to include in the client's plan of care?

Correct Answer: B

Rationale: A WBC of 500/mm3 indicates severe neutropenia, increasing infection risk. Avoiding crowds and sick people (
B) is critical. Hypothermia (
A) is not a primary concern, soft toothbrush (
C) prevents bleeding, and bleeding (
D) is for thrombocytopenia.

Question 5 of 5

A male client has heart failure. He has been instructed to gradually increase his activities. Which signs and symptoms of worsening heart failure should the nurse tell him to watch for that would indicate a need for him to lower his activity level?

Correct Answer: D

Rationale: Pain in the legs could be indicative of doing too much too quickly, but not of worsening heart failure. The client should be cautioned to increase his activities slowly. Thirst, weight loss, and frequent urination are not indicative of heart failure. The client should report these symptoms to his physician. Drowsiness and lethargy are not indicative of worsening heart failure. The client should report these symptoms to his physician. All of these symptoms indicate a worsening cardiac condition possibly associated with too much activity. The client's activity level should be evaluated.

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