Nokea
24 hours after undergoing kidney transplantation, a client develops a hyperacute rejection. To correct this problem, the nurse should prepare the client for:
- A. Removal of the transplanted kidney
- B. High-dose IV cyclosporine (Sandimmune) therapy
- C. Bone marrow transplant
- D. Intra-abdominal instillation of methylprednisolone sodium succinate (Solu-Medrol)
Correct Answer: A
Rationale: The correct answer is A: Removal of the transplanted kidney. Hyperacute rejection is a severe and immediate immune response to the transplanted organ. In this case, the transplanted kidney must be removed promptly to prevent further complications, as it is irreversibly damaged. High-dose IV cyclosporine (B) is used for immunosuppression but is not effective in treating hyperacute rejection. Bone marrow transplant (C) is not indicated for kidney rejection. Intra-abdominal instillation of methylprednisolone sodium succinate (D) is used for acute rejection, not hyperacute rejection.
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The nurse is preparing a client for magnetic resonance imaging (MRI) to confirm or rule out a spinal cord lesion. During the MRI scan, which of the following would pose a threat to the client?
- A. The client lies still.
- B. The client wears a watch and wedding
- C. The client asks questions. band.
- D. the client hears thumping sounds.
Correct Answer: B
Rationale: The correct answer is B: The client wears a watch and wedding band. This is because metal objects such as watches and jewelry can be hazardous during an MRI scan due to the strong magnetic field, leading to potential movement or heating of the metal objects, causing harm to the client.
A: The client lies still - This is important for obtaining clear images during an MRI scan and does not pose a threat to the client.
C: The client asks questions - Asking questions during an MRI scan does not pose a direct threat to the client's safety.
D: The client hears thumping sounds - Thumping sounds are a normal part of the MRI scan and do not pose a threat to the client's safety.
A client with diabetes mellitus has a prescription for 5 U-100 regular insulin and 25 U of U-100 isophane insulin suspension (NPH) to be taken before breakfast. At about 4:30 p.m., the client experiences headache, sweating, tremor, pallor, and nervousness. What is the most probable cause of these signs and symptoms?
- A. Hyperglycemia
- B. Hyperuricemia
- C. Hypoglycemia
- D. Hypochondria
Correct Answer: C
Rationale: The correct answer is C: Hypoglycemia. At 4:30 p.m., after taking the morning insulin, the client's blood sugar may have dropped too low, leading to symptoms like headache, sweating, tremor, pallor, and nervousness. Regular insulin and NPH insulin peak at different times, causing a potential mismatch in insulin action, leading to hypoglycemia. Hyperglycemia (A) would present with different symptoms like increased thirst and urination. Hyperuricemia (B) is an excess of uric acid in the blood and does not typically present with these symptoms. Hypochondria (D) is a psychological condition and not related to the client's physical symptoms.
Antibodies are made of which of the following types of substances?
- A. Fat
- B. Protein
- C. Sugar
- D. Carbohydrates CARE OF PATIENTS WITH IMMUNE DISORDERS
Correct Answer: B
Rationale: The correct answer is B: Protein. Antibodies are a type of protein produced by the immune system to help identify and neutralize pathogens like bacteria and viruses. Proteins are composed of amino acids, which are the building blocks of proteins. Antibodies have a specific structure that allows them to bind to specific antigens. Fat (A), Sugar (C), and Carbohydrates (D) are not primary components of antibodies and do not play a significant role in their structure or function.
With severe diarrhea, electrolytes as well as fluids are lost. What electrolyte imbalance is indicated in Ms. CC’s decreased muscle tone and deep tendon reflexes?
- A. Hypernatremia
- B. Hyperchoremia
- C. Hypokalemia
- D. Hypocalcemia
Correct Answer: D
Rationale: The correct answer is D: Hypocalcemia. Severe diarrhea can lead to electrolyte imbalances, including low calcium levels. Decreased muscle tone and deep tendon reflexes are classic signs of hypocalcemia. Calcium is essential for proper muscle function and nerve transmission. Hypernatremia (A) is high sodium levels, not related to decreased muscle tone. Hyperchloremia (B) is high chloride levels, not associated with muscle tone changes. Hypokalemia (C) is low potassium levels, which can cause muscle weakness but not specifically decreased muscle tone and deep tendon reflexes like hypocalcemia.
To prevent leakage of fluid in the thoracic cavity, how will you position the client after thoracentesis?
- A. Place flat in bed
- B. Turn on the affected side
- C. Turn on the unaffected side
- D. On bed rest SENSORY DISORDERS
Correct Answer: B
Rationale: The correct answer is B: Turn on the affected side. This position helps to promote the closure of the puncture site in the lung, reducing the risk of fluid leakage and pneumothorax. Placing the client flat in bed (A) may not allow gravity to assist in the closure of the puncture site. Turning on the unaffected side (C) may not effectively prevent fluid leakage from the puncture site. Bed rest (D) is a general instruction and does not specifically address the prevention of fluid leakage after thoracentesis.