Fundamentals - Physiological Aspects nclex compass Hesi 2023
The nurse assesses an edematous client and recalls that edema occurs in what extracellular fluid compartment? 1.Interstitial 2.Intercellular 3.Intravascular 4.Intracellular
1.Interstitial
A child is to receive 60 mg of phenytoin (Dilantin). The medication is available as an oral suspension that contains 125 mg/5 mL. How many milliliters should the nurse administer? Record the answer using one decimal place. ______ mL
Desire 60 mg = x mL Have 125 mg 5 mL 125x = 300 X = 300 ÷ 125 = 2.4 mL
A physician orders heparin 6,000 units subcutaneously daily. The pharmacy dispenses a vial containing 10,000 units per milliliter. To ensure the patient's safety, how many milliliters of heparin should the nurse administer? Include a leading zero if applicable. Record your answer using one decimal place. ______ mL
10,000 units/1 mL = 6,000 units/x 10,000 units (x) = 6,000 units (mL) x = 6,000 units (mL) / 10,000 units x = 0.6 mL
The nurse understands that the action of an antidiuretic hormone (ADH) is to: 1.Reduce blood volume. 2.Decrease water loss in urine. 3.Increase urine output. 4.Initiate the thirst mechanism.
2.Decrease water loss in urine.
A client had extensive, prolonged surgery. Which electrolyte level should the nurse monitor most closely? 1.Sodium 2.Calcium 3.Chloride 4.Potassium
4.Potassium
A client who sustained a large open wound as a result of an accident is receiving daily sterile dressing changes. To maintain sterility when changing the dressing, the nurse should: 1.Put the unopened sterile glove package carefully on the sterile field 2.Remove the sterile drape from its package by lifting it by the corners 3.Don sterile gloves before opening the package containing the field drape 4.Pour irrigation liquid from a height of at least three inches above the sterile container
2.Remove the sterile drape from its package by lifting it by the corners
A client's intravenous (IV) infusion infiltrates. The nurse concludes that what is most likely the cause of the infiltration? 1.Excessive height of the IV bag 2.Failure to secure the catheter adequately 3.Contamination during the catheter insertion 4.Infusion of a chemically irritating medication
2.Failure to secure the catheter adequately
A health care provider prescribes 250 mg of a medication. The vial reads 500 mg/mL. How much medication (mL) should the nurse administer? Include a leading zero if applicable. Record your answer using one decimal place. _____ mL
250 mg/X=500 mg/1 mL 500x=250 X=1/2 mL or 0.5
A nurse applies a cold pack to treat an acute musculoskeletal injury. Cold therapy decreases pain by: 1.Promoting analgesia and circulation 2.Numbing the nerves and dilating the blood vessels 3.Promoting circulation and reducing muscle spasms 4.Causing local vasoconstriction, preventing edema and muscle spasm
4.Causing local vasoconstriction, preventing edema and muscle spasm
A client with a diagnosis of uncontrolled diabetes began receiving Lasix (Furosemide) two days ago. The nurse reviews the morning lab results and discovers that the client's potassium level is 2.8 mEq/L. What is the most appropriate action for the nurse to take? 1.Hold the morning dose of the diuretic and have the lab repeat the test. 2.Continue to monitor the level to ensure that it stays within the normal limits. 3.Notify the primary healthcare provider of the result, which is critically low. 4.Anticipate a prescription for an increase in the dosage of the Lasix.
3.Notify the primary healthcare provider of the result, which is critically low.
A client develops an increased temperature after surgery. Ceftriaxone (Rocephin) is prescribed. For which potential effect should the nurse monitor the client? 1.Dehydration 2.Heart failure 3.Constipation 4.Allergic response
4.Allergic response
What response should a nurse be particularly alert for when assessing a client for side effects of long-term cortisone therapy? 1.Hypoglycemia 2.Severe anorexia 3.Anaphylactic shock 4.Behavioral changes
4.Behavioral changes
