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Questions 164

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Extract:

Home Medications

Vital signs

Temperature 98.5 F (36.9 C)
Blood pressure 110/74 mm Hg
Heart rate 68/min
Respirations 16/min
SpO2 97% on room air
Medication Prescription
Medication prescription

Clopidogrel: 75 mg PO, daily
Metoprolol XL: 50 mg PO, daily
Furosemide: 40 mg PO, twice daily
Fish oil: 4 g PO, daily

Intake and Output Record
Intake and output record

Time Oral Intake Output
0700 200 mL
0800 125 mL
1000 100 mL 250 mL
1200 200 mL 250 mL
1500 150 mL 375 mL


Question 1 of 5

The nurse is caring for a client with coronary artery disease and heart failure. Which of the following findings would require immediate follow-up?

Correct Answer: C

Rationale: Hypokalemia (serum potassium <3.5 mEq/L [<3.5 mmol/L]) is a common adverse effect of potassium-wasting diuretics (eg,furosemide) that may cause leg cramps, muscle weakness, or ECG changes. Unmanaged hypokalemia can lead to lethal cardiac dyshythmias (eg, ventricular fibrillation, torsades de pointes) and paralysis.
Therefore, the nurse should immediately notify the health care provider of symptoms of hypokalemia

Extract:


Question 2 of 5

The nurse is responsible for teaching the client regarding dietary choices to provide needed magnesium. Which food is a good source of magnesium?

Correct Answer: B

Rationale: Spinach is a rich source of magnesium, found in green leafy vegetables, nuts, and whole grains. Apple , liver , and squash have lower magnesium content.

Extract:

Laboratory reference ranges
Glucose (fasting)
70–110 mg/dL
(3.9–6.1 mmol/L)


Question 3 of 5

The nurse is caring for a client who has acute pancreatitis. Which of the following findings is most concerning?

Correct Answer: C

Rationale: Fever (102.2°F) with increasing abdominal pain suggests infection or abscess, a life-threatening complication of pancreatitis. Hyperglycemia, knee-flexed positioning, and diarrhea are concerning but less urgent.

Extract:


Question 4 of 5

The nurse is caring for a client diagnosed with polycythemia vera. Which statement by the client requires immediate follow-up?

Correct Answer: B

Rationale: Massaging a sore, swollen leg risks dislodging a clot in polycythemia vera, which predisposes to thrombosis. Ruddy complexion, aspirin use, and itching are expected but less urgent.

Question 5 of 5

All of the following clients need attention. Which one should the nurse go to first?

Correct Answer: A

Rationale: Severe headache and blurred vision in spinal cord injury suggest autonomic dysreflexia, a life-threatening emergency, prioritizing immediate attention over turning, examination, or ambulation.

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