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Questions 164

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Question 1 of 5

The client is receiving furosemide (Lasix) 80 mgm. Which is a sign of a possible complication of the administration of furosemide?

Correct Answer: A

Rationale: Furosemide is a loop diuretic that can cause electrolyte imbalances, such as hypokalemia, which may lead to tachycardia. Hypertension is not a common complication; polyuria is an expected effect, not a complication; and eupnea (normal breathing) is unrelated.

Question 2 of 5

The nurse is caring for a client who has no pulse and is experiencing the cardiac rhythm in the ECG strip shown below. The client has a do not attempt resuscitation directive. The health care provider (HCP) orders initiation of resuscitative measures. Which of the following actions should the nurse take?

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Correct Answer: B

Rationale: A client with a Do Not Attempt Resuscitation (DNAR) or Do Not Resuscitate (DNR) directive has legally chosen not to receive resuscitative measures, such as CPR or defibrillation, in the event of cardiac arrest. The nurse has an ethical and legal obligation to honor the client's advanced directive.

Question 3 of 5

The nurse is reviewing discharge instructions with a client going home on linezolid therapy for a vancomycin-resistant enterococcus infection. Which client statement requires further teaching?

Correct Answer: A

Rationale: Linezolid interacts with SSRIs like paroxetine, risking serotonin syndrome, requiring a washout period. Acetaminophen is safe, tyramine avoidance prevents hypertensive crises, and reporting fever/diarrhea monitors treatment response.

Question 4 of 5

The parents of a 2 year-old child report that he has been holding his breath whenever he has temper tantrums. What is the best action by the nurse?

Correct Answer: C

Rationale: Advise the parents to ignore breath holding because breathing will begin as a reflex. Breath-holding is benign and self-resolving in toddlers.

Question 5 of 5

The nurse is talking with the spouse of a client who is eligible for hospice care. The spouse states, 'I do not know if I can make this decision. What would you do?' Which of the following responses would be appropriate for the nurse to make?

Correct Answer: A

Rationale: The nurse should remain neutral and facilitate discussion about the client's values and preferences, helping the spouse make an informed decision without personal bias or directing to other resources prematurely.

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