Nokea
The nurse is caring for a patient who is taking trimethoprim-sulfamethoxazole (TMP-SMX). The nurse learns that the patient takes an angiotensin-converting enzyme (ACE) inhibitor. To monitor for drug interactions, the nurse will request an order for which laboratory test(s)?
- A. A complete blood count
- B. BUN and creatinine
- C. Electrolytes
- D. Glucose
Correct Answer: C
Rationale: The correct answer is 'C. Electrolytes.' When trimethoprim-sulfamethoxazole (TMP-SMX) is taken with an ACE inhibitor, there is an increased risk of hyperkalemia due to the combined effects on potassium levels. Monitoring electrolytes, specifically potassium, is essential to detect and manage this potential drug interaction. Choices A, B, and D are incorrect because while they are important tests in general patient care, they are not specifically indicated to monitor for the drug interaction between TMP-SMX and ACE inhibitors.
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Oxygen via nasal cannula has been prescribed for a client with emphysema. The nurse checks the physician's orders to ensure that the prescribed flow is not greater than:
- A. 1 L/min
- B. 3 L/min
- C. 4 L/min
- D. 6 L/min
Correct Answer: B
Rationale: The correct answer is B, 3 L/min. Clients with emphysema typically receive oxygen at a flow rate of 1 to 2 L/min, with a maximum of 3 L/min. Higher flow rates can lead to oxygen toxicity in these clients, so it's crucial to adhere to the prescribed limits. Choice A (1 L/min) is too low and may not provide adequate oxygenation for the client. Choices C (4 L/min) and D (6 L/min) exceed the recommended flow rates for clients with emphysema and can increase the risk of oxygen toxicity.
The nurse is administering intravenous fluids to a dehydrated patient. On the second day of care, the patient's weight has increased by 2.25 pounds. The nurse would expect that the patient's fluid intake has
- A. equaled urine output.
- B. exceeded urine output by 1 L.
- C. exceeded urine output by 2.5 L.
- D. exceeded urine output by 3 L.
Correct Answer: B
Rationale: A weight gain of 1 kg, or approximately 2.2 to 2.5 lb, is generally equivalent to 1 liter (L) of fluid retained by the body. In this case, the patient's weight gain of 2.25 pounds suggests an excess fluid retention of approximately 1 liter, indicating that the patient's fluid intake has exceeded urine output by 1 liter. Choices C and D are incorrect as they overestimate the fluid excess based on the patient's weight gain. Choice A is incorrect as it implies an exact balance between fluid intake and urine output, which is not reflected in the given weight increase.
A client with kidney stones from secondary hyperoxaluria requires medication. Which medication should the nurse anticipate administering?
- A. Phenazopyridine (Pyridium)
- B. Propantheline (Pro-Banthine)
- C. Tolterodine (Detrol LA)
- D. Allopurinol (Zyloprim)
Correct Answer: D
Rationale: The correct answer is D: Allopurinol (Zyloprim). Allopurinol is used to treat kidney stones caused by secondary hyperoxaluria. This medication helps prevent the formation of certain types of kidney stones. Choices A, B, and C are incorrect. Phenazopyridine (Pyridium) is given to clients with urinary tract infections, not for kidney stones. Propantheline (Pro-Banthine) is an anticholinergic medication used for treating certain gastrointestinal conditions, not kidney stones. Tolterodine (Detrol LA) is also an anticholinergic with smooth muscle relaxant properties, primarily used to treat overactive bladder conditions, not kidney stones.
A client is getting out of bed for the first time since surgery. The client complains of dizziness after the nurse raises the head of the bed. Which of the following actions should the nurse take first?
- A. Checking the client's blood pressure
- B. Checking the oxygen saturation level
- C. Having the client take some deep breaths
- D. Lowering the head of the bed slowly until the dizziness is relieved
Correct Answer: D
Rationale: When a client experiences dizziness after being positioned upright for the first time post-surgery, the initial action the nurse should take is to lower the head of the bed slowly until the dizziness subsides. This maneuver helps alleviate the dizziness by allowing the body to adapt gradually to the change in position. Subsequently, the nurse should assess the client's pulse and blood pressure. Checking the blood pressure is essential to evaluate the circulatory status and rule out orthostatic hypotension as a cause of dizziness. Checking the oxygen saturation level and having the client take deep breaths are not the priority in this scenario as the primary concern is addressing the circulatory issue causing dizziness, not a respiratory problem.
A nurse obtains a sterile urine specimen from a client's Foley catheter. After applying a clamp to the drainage tubing distal to the injection port, which action should the nurse take next?
- A. Clamp another section of the tube to create a fixed sample section for retrieval.
- B. Insert a syringe into the injection port and aspirate the quantity of urine required.
- C. Clean the injection port cap of the drainage tubing with a povidone-iodine solution.
- D. Withdraw 10 mL of urine and discard it; then withdraw a fresh sample of urine.
Correct Answer: C
Rationale: The correct next action for the nurse to take after applying a clamp to the drainage tubing distal to the injection port is to clean the injection port cap of the catheter drainage tubing with an appropriate antiseptic like povidone-iodine solution or alcohol. This step is crucial to prevent surface contamination before taking the urine sample. Clamping another section of the tube to create a fixed sample section or withdrawing and discarding urine are unnecessary and could lead to potential contamination. Inserting a syringe into the injection port and aspirating the required amount of urine directly from the catheter is the correct method for obtaining the urine sample, but cleaning the injection port cap should precede this step to ensure sterility.