Question

A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?

Answer 1

Correct Answers:

Measure urinary output every hour

Rationale :

💉Dopamine stimulates renal perfusion at moderate doses like 8 mcg/kg/min.

📊Urinary output is a direct and essential indicator of kidney perfusion status.

🧪Monitoring urine hourly helps evaluate whether renal blood flow is improving as intended.

⚠️Decreased urine could signal renal hypoperfusion or drug ineffectiveness, needing urgent intervention.

📌Core Message

Urinary output is a key marker of renal perfusion when administering dopamine.

Answer 2

Correct Answers:

Watery diarrhea

Rationale :

💊Linezolid may cause Clostridioides difficile infection, especially with prolonged IV use.

🚨Watery diarrhea is an early sign of this potentially life-threatening complication.

📞The nurse must alert the provider to prevent escalation into severe colitis or sepsis.

📉Less urgent symptoms like fatigue or yellow sputum are not indicators of acute complications.

📌Core Message

Watery diarrhea signals possible C. difficile colitis, a dangerous side effect of linezolid.

Answer 3

Correct Answers:

Reassure the client that facial flushing is a common side effect of the medication.

Rationale :

💊Lisinopril, an ACE inhibitor, commonly causes facial flushing due to vasodilation, especially if the dose is higher than usual.

😊Mild flushing without other symptoms such as chest pain, dyspnea, or swelling does not typically indicate a serious reaction.

📞Since the client denies chest discomfort or respiratory symptoms, this presentation does not warrant emergency intervention.

📘The nurse should reassure the client but also provide education about signs of angioedema, which require urgent care.

📌Core Message

Facial flushing can be a common and benign side effect of ACE inhibitors like lisinopril, not always needing emergency care.

Answer 4

Correct Answers:

Keep chest tube container below the site of insertion.

Rationale :

🩺Gravity-dependent drainage is essential for proper function of the chest tube system.

⚠️Placing the container above chest level can cause backflow of air or fluid, risking tension pneumothorax.

🚑This is especially critical during transport, when changes in position can disrupt fluid dynamics.

📉Marking drainage or securing tubing are helpful, but not as vital as maintaining correct system position.

📌Core Message

A chest tube system must stay below chest level to ensure safe and effective drainage.

Answer 5

Correct Answers:

Withhold this dose.

Rationale :

👶Infants are at increased risk of digoxin toxicity, and re-dosing after vomiting can lead to overdose.

🕒Since vomiting occurred 20 minutes after administration, some absorption may have already happened.

⚠️Administering more could exceed the narrow therapeutic window of digoxin.

📞The safest course is to withhold the dose and consult the provider before giving more.

📌Core Message

To avoid toxicity, a vomited dose of digoxin should be withheld unless directed otherwise.

Answer 6

Correct Answers:

Observe insertion site.

Rationale :

🧼The suprapubic catheter site is prone to infection, especially in home settings.

👁️Visual inspection helps detect redness, discharge, or swelling early.

🩺Ongoing skin assessments reduce the risk of complications like cellulitis or abscess.

📉Other assessments like perineal or flank checks are less specific to suprapubic entry.

📌Core Message

Directly observing the insertion site is essential to detect early signs of infection in suprapubic catheters.

Answer 7

Correct Answers:

Ensure the client receives frequent small meals containing complete proteins

Rationale :

🥚A serum albumin level of 1.5 g/dL indicates severe protein malnutrition.

🍽️Frequent intake of complete proteins supports wound healing, immunity, and fluid balance.

📉Edema and weight loss signal catabolism and hypoalbuminemia, requiring nutritional correction.

⚠️Fluid restrictions or support stockings do not address the underlying protein deficiency.

📌Core Message

Clients on peritoneal dialysis with low albumin need high-protein nutrition to restore balance and healing.

Answer 8

Correct Answers:

Consume foods with saturated fats.
Use a salt substitute.
Eat more canned vegetables.

Rationale :

🍔Saturated fats contribute to atherosclerosis and must be reduced in heart-healthy diets.

🧂Salt substitutes often contain potassium, which can be dangerous for clients on ACE inhibitors.

🥫Canned vegetables typically contain high sodium, which worsens hypertension and fluid retention.

🚶Walking, food journaling, and oatmeal consumption are beneficial for cardiovascular health.

📚Identifying poor choices helps guide client teaching on modifying risks for coronary artery disease.

📌Core Message

Heart disease prevention requires avoiding saturated fats, sodium-rich foods, and cautious use of salt substitutes.

Answer 9

Correct Answers:

Maintain a continuous infusion of IV fluids per prescription

Rationale :

🧪Pyloric stenosis causes projectile vomiting leading to metabolic alkalosis and dehydration.

💉IV fluids correct electrolyte imbalances and prevent complications during anesthesia.

🚼Infants need stabilized fluid and acid-base balance before surgery to prevent cardiac dysrhythmias.

📝Parent education and mass marking are important, but fluid correction is the top priority.

📌Core Message

For infants with pyloric stenosis, IV fluid resuscitation is critical to correct dehydration and electrolyte imbalance before surgery.

Answer 10

Correct Answers:

Provide supplemental oxygen.

Rationale :

🫁Pulmonary embolism causes impaired gas exchange due to blocked pulmonary circulation.

💨Administering oxygen helps relieve hypoxia and supports tissue oxygenation while awaiting further treatment.

📞Notifying the provider and preparing heparin are necessary but come after addressing immediate respiratory compromise.

📦Bringing the crash cart is not the priority unless cardiac arrest is occurring.

📌Core Message

Oxygen administration is the first response to a suspected pulmonary embolism to prevent hypoxia.

1 :
A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?

2 :
In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the health care provider?

3 :
A male client reports to the on-call clinic nurse that he took two tablets of 10 mg lisinopril by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina, but denies experiencing any chest pain at the moment or recently. Which action should the nurse take?

4 :
A client is being urgently transported to radiology for a Computerized Tomography (CT scan) after a sudden decrease in level of consciousness. The client is orally intubated and has a left lateral chest tube to 20 cm suction. Which action is most important for the nurse to take?

5 :
A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her a-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

6 :
Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?

8 :
The nurse is providing lifestyle change education for a client to slow the progression of coronary artery disease. Which statement(s) made by the client should the nurse recognize as needing additional education? (Select all that apply.)

9 :
A 6-week-old infant with poor weight gain is scheduled for a pyloromyotomy. Which pre-operative nursing action has the highest priority?

10 :
Two days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing. The nurse suspects the client had a pulmonary embolus. Which action should the nurse take first?

1 : A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?

2 : In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the health care provider?

3 : A male client reports to the on-call clinic nurse that he took two tablets of 10 mg lisinopril by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina, but denies experiencing any chest pain at the moment or recently. Which action should the nurse take?

4 : A client is being urgently transported to radiology for a Computerized Tomography (CT scan) after a sudden decrease in level of consciousness. The client is orally intubated and has a left lateral chest tube to 20 cm suction. Which action is most important for the nurse to take?

5 : A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her a-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

6 : Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?

8 : The nurse is providing lifestyle change education for a client to slow the progression of coronary artery disease. Which statement(s) made by the client should the nurse recognize as needing additional education? (Select all that apply.)

9 : A 6-week-old infant with poor weight gain is scheduled for a pyloromyotomy. Which pre-operative nursing action has the highest priority?

10 : Two days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing. The nurse suspects the client had a pulmonary embolus. Which action should the nurse take first?

1 :
A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?

2 :
In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the health care provider?

3 :
A male client reports to the on-call clinic nurse that he took two tablets of 10 mg lisinopril by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina, but denies experiencing any chest pain at the moment or recently. Which action should the nurse take?

4 :
A client is being urgently transported to radiology for a Computerized Tomography (CT scan) after a sudden decrease in level of consciousness. The client is orally intubated and has a left lateral chest tube to 20 cm suction. Which action is most important for the nurse to take?

5 :
A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her a-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

6 :
Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?

8 :
The nurse is providing lifestyle change education for a client to slow the progression of coronary artery disease. Which statement(s) made by the client should the nurse recognize as needing additional education? (Select all that apply.)

9 :
A 6-week-old infant with poor weight gain is scheduled for a pyloromyotomy. Which pre-operative nursing action has the highest priority?

10 :
Two days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing. The nurse suspects the client had a pulmonary embolus. Which action should the nurse take first?