Nokea
A nurse is caring for a client who has dumping syndrome following a gastric resection. The nurse should monitor the client for which of the following complications of dumping syndrome?
- A. Hyperkalemia
- B. Hypoglycemia
- C. Iron-deficiency anemia
- D. Hypertension
Correct Answer: C
Rationale: The correct answer is C: Iron-deficiency anemia. Dumping syndrome following a gastric resection can lead to rapid emptying of the stomach contents into the small intestine, causing malabsorption of nutrients, especially iron. Iron-deficiency anemia can develop due to inadequate iron absorption. Monitoring for anemia is crucial in these clients.
Hyperkalemia (A), hypoglycemia (B), and hypertension (D) are not typical complications of dumping syndrome. Hyperkalemia is high potassium levels, hypoglycemia is low blood sugar, and hypertension is high blood pressure, which are not directly associated with dumping syndrome.
You may also like to solve these questions
A nurse is assessing a client who has a chest tube connected to a closed water-seal drainage system. Which of the following findings should the nurse report to the provider?
- A. Constant bubbling in the water seal chamber
- B. Intermittent bubbling in the suction chamber
- C. Clear drainage of 50 mL over 8 hours
- D. Mild pain at the insertion site
Correct Answer: A
Rationale: The correct answer is A: Constant bubbling in the water seal chamber. This finding indicates an air leak in the system, which can compromise the client's respiratory status. The continuous bubbling signifies that air is escaping through the chest tube rather than being properly drained. The nurse should report this to the provider immediately for further evaluation and intervention to prevent pneumothorax or other complications.
The other choices (B, C, D) are incorrect because intermittent bubbling in the suction chamber is expected as it indicates proper functioning of the system. Clear drainage of 50 mL over 8 hours is within normal limits and does not pose an immediate threat to the client. Mild pain at the insertion site is also a common finding after chest tube insertion and does not require urgent intervention unless it worsens or is accompanied by other concerning symptoms.
A nurse is assessing a client who has a new diagnosis of diabetes mellitus. The nurse should identify that which of the following findings is a manifestation of hyperglycemia?
- A. Sweating
- B. Increased thirst
- C. Shakiness
- D. Decreased urination
Correct Answer: B
Rationale: Correct Answer: B - Increased thirst
Rationale: Hyperglycemia results in elevated blood glucose levels, which leads to osmotic diuresis and fluid loss, causing increased thirst. Sweating (A) is more commonly associated with hypoglycemia. Shakiness (C) is a symptom of hypoglycemia due to low blood sugar levels. Decreased urination (D) is not a typical manifestation of hyperglycemia as it is more commonly associated with conditions like dehydration or kidney issues.
A nurse is caring for a client who has deep-vein thrombosis and is receiving heparin via continuous IV infusion. The clients weight is 80 kg (176.4 lb). Using the client information provided, which of the following actions should the nurse take?
- A. Increase the infusion rate.
- B. Administer protamine sulfate immediately.
- C. Stop the heparin infusion for 1 hr.
- D. Decrease the heparin dose.
Correct Answer: C
Rationale: The correct answer is C: Stop the heparin infusion for 1 hr. This is because the client's weight is crucial in determining the appropriate heparin dosage. Heparin is usually dosed based on the client's weight to prevent complications such as bleeding or clotting. In this case, the client's weight of 80 kg indicates a specific dose range for heparin. Stopping the infusion for 1 hour allows the nurse to reassess the client's condition and potentially adjust the heparin dosage to ensure it is safe and effective.
A: Increasing the infusion rate without proper assessment can lead to overdose and increased risk of bleeding.
B: Administering protamine sulfate is the antidote for heparin overdose, not indicated in this scenario.
D: Decreasing the heparin dose without assessment may result in inadequate anticoagulation and increased risk of clot formation.
A nurse is providing preoperative teaching to a client who is scheduled for a radical prostatectomy. Which of the following information should the nurse include in the teaching?
- A. You will have a urinary catheter for several days.
- B. A PCA pump will be used for postoperative pain control.
- C. You will be discharged the same day as surgery.
- D. You should avoid all fluid intake after surgery.
Correct Answer: B
Rationale: The correct answer is B: A PCA pump will be used for postoperative pain control. This is crucial information for the client undergoing a radical prostatectomy as it ensures effective pain management post-surgery. The use of a PCA pump allows the client to self-administer pain medication within safe limits, promoting better pain control and comfort during the recovery period. It also empowers the client to actively participate in their pain management.
Choice A is incorrect because while the client may have a urinary catheter after surgery, it is not the most crucial information to include in preoperative teaching.
Choice C is incorrect as radical prostatectomy typically requires a hospital stay, not same-day discharge.
Choice D is incorrect as avoiding all fluid intake after surgery is not recommended; adequate hydration is important for recovery.
A nurse is caring for a client who is hemorrhaging and hypotensive from esophageal variceal bleeding. Which of the following actions should the nurse take first?
- A. Administer a vasopressor.
- B. Verify that the client has adequate IV access.
- C. Place the client in the Trendelenburg position.
- D. Prepare for endoscopic intervention.
Correct Answer: B
Rationale: The correct answer is B: Verify that the client has adequate IV access. This is the priority action because the client is hypotensive from hemorrhaging, indicating a need for immediate fluid resuscitation to stabilize their condition. Without adequate IV access, the nurse cannot administer life-saving fluids and medications. Administering a vasopressor (A) or preparing for endoscopic intervention (D) may be necessary later but addressing the hypotension is the priority. Placing the client in Trendelenburg position (C) is not recommended as it can increase intracranial pressure.