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A 62-year old client diagnosed with pyelonephritis and possible septicemia has had five urinary tract infections over the past 2 years. She's fatigued from lack of sleep; urinates frequently, even during the night, and has lost weight recently. Tests reveal the following: sodium level 152mEq/L, osmolarity 340mOsm/L, glucose level 125mg/dl, and potassium level of 3.8mEq/L. Which of the following nursing diagnoses is most appropriate for this client?
- A. Deficient fluid volume related to inability to conserve water
- B. Imbalanced nutrition: Less than body requirements related to hypermetabolic state
- C. Deficient fluid volume related to osmotic diuresis induced by hypernatremia
- D. Imbalanced nutrition: Less than body requirements related to catabolic effects of insulin deficiency
Correct Answer: C
Rationale: The client's elevated sodium level of 152 mEq/L indicates hypernatremia, which can lead to osmotic diuresis, causing excessive urination and subsequent fluid loss. This fluid loss can result in deficient fluid volume. The client's symptoms of frequent urination, fatigue from lack of sleep, and weight loss are indicative of dehydration due to the osmotic diuresis. Therefore, the most appropriate nursing diagnosis for this client is Deficient fluid volume related to osmotic diuresis induced by hypernatremia.
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Which of the ff nursing interventions is essential for a client during the Schilling test?
- A. Collecting urine 24-48 hrs after the client has received nonradioactive B12
- B. Collecting blood samples of 50 ml for 24-48 hrs after the client has received the nonradioactive B12
- C. Not allowing any oral fluid consumption for 24-48 hrs after the client has received nonradioactive B12
- D. Making the client lie down in the supine position for 24-48 hrs after the client has received nonradioactive B12 CARING FOR CLIENTS WITH DISORDERS OF THE HEMATOPOIETIC SYSTEM
Correct Answer: A
Rationale: During the Schilling test, which is used to evaluate the absorption of vitamin B12 in the gastrointestinal system, the essential nursing intervention is to collect urine samples 24-48 hours after the client has received nonradioactive B12. The test involves administering both radioactive and nonradioactive forms of vitamin B12 to the client. The client's ability to absorb the vitamin B12 is assessed by measuring the amount of labeled B12 in the urine over the specified time period. This helps in diagnosing conditions such as pernicious anemia or malabsorption of vitamin B12. Blood samples are not typically collected for this test, and allowing fluid consumption is important to keep the client hydrated. The client does not need to lie down in a specific position for an extended period following nonradioactive B12 administration.
What equipment should the nurse prepare for the primary care provider when a woman says she is concerned about possible Chlamydia infection?
- A. Chlamydia slide
- B. Chlamydia collection kit
- C. Chlamydia swab
- D. Chlamydia wet mount
Correct Answer: B
Rationale: When a woman expresses concerns about a possible Chlamydia infection, the nurse should prepare a Chlamydia collection kit for the primary care provider. This kit typically includes everything needed to collect a specimen for testing, such as a swab for the patient to provide a genital sample. This sample can then be sent to a laboratory for testing to confirm the presence of Chlamydia. Having the appropriate collection kit ready ensures that the primary care provider can promptly gather the necessary information to make an accurate diagnosis and provide appropriate treatment if needed.
A nurse is working with a dying client and his family. Which communication technique is most important to use?
- A. Reflection
- B. Clarification
- C. Interpretation
- D. Active listening
Correct Answer: D
Rationale: Active listening is the most important communication technique to use when working with a dying client and their family. This technique involves the nurse fully concentrating, understanding, responding, and remembering what is being said. By actively listening, the nurse can provide empathy, support, and validation to the client and their family members during this emotionally challenging time. This technique helps in creating a safe and supportive environment for honest and open communication, allowing the nurse to assess and address the needs and concerns of both the client and their family effectively.
A client is scheduled to receive methotrexate (Folex), 0.625 mg/kg P.O. daily, to treat malignant lymphoma. Before administering the drug, the nurse reviews the client's medication history. Which of the following drugs might interact with methotrexate?
- A. digoxin (Lanoxin)
- B. Probenecid (Benemid)
- C. theophylline (Slo-Phyllin)
- D. Famotidine (Pepcid)
Correct Answer: B
Rationale: Probenecid is a drug that can interact with methotrexate by inhibiting its renal tubular secretion, leading to increased methotrexate levels and potential toxicity. It is essential to monitor the client closely for signs of methotrexate toxicity if both drugs are being used concurrently. The other options, digoxin, theophylline, and famotidine, do not have significant interactions with methotrexate that would result in increased toxicity.
The school nurse is conducting a class for school-age children on Lyme disease. Which is characteristic of Lyme disease?
- A. Difficult to prevent
- B. Treated with oral antibiotics in stages 1, 2, and 3
- C. Caused by a spirochete that enters the skin through a tick bite
- D. Common in geographic areas where the soil contains the mycotic spores that cause the disease
Correct Answer: C
Rationale: Lyme disease is caused by a spirochete bacterium called Borrelia burgdorferi, which enters the skin through the bite of an infected deer tick. It is primarily transmitted to humans through the bite of infected black-legged ticks, commonly known as deer ticks. These ticks carry the bacterium in their gut and can transmit it to humans when they feed on blood. Therefore, Lyme disease is characterized by being caused by a spirochete that enters the skin through a tick bite. Option C is the correct answer in this case, as options A, B, and D do not accurately describe the characteristics of Lyme disease.