Nokea
A client diagnosed with multiple myeloma is receiving intravenous hydration at 100 mL per hour. Which finding indicates to the nurse that the client is experiencing a positive response to the treatment plan?
- A. Weight increase of 1 kilogram
- B. Respirations of 18 breaths per minute
- C. Creatinine of 1.0 mg/dL (88 mcmol/L)
- D. White blood cell count of 6000 mm3 (6 × 109/L)
Correct Answer: C
Rationale: Multiple myeloma is a malignant proliferation of plasma cells within the bone. Renal failure is a concern in the client with multiple myeloma. In multiple myeloma, hydration is essential to prevent renal damage resulting from precipitation of protein in the renal tubules and excessive calcium and uric acid in the blood. Creatinine is the most accurate measure of renal function. Options 2 and 4 are unrelated to the subject of hydration. Weight gain is not a positive sign when concerned with renal status.
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A client is diagnosed with hypothyroidism. The nurse performs an assessment on the client, expecting to note which findings? Select all that apply.
- A. Weight loss
- B. Bradycardia
- C. Hypotension
- D. Dry, scaly skin
- E. Heat intolerance
- F. Decreased body temperature
Correct Answer: B,C,D,F
Rationale: The manifestations of hypothyroidism are the result of decreased metabolism from low levels of thyroid hormones. Some of these manifestations are bradycardia; hypotension; cool, dry, scaly skin; decreased body temperature; dry, coarse, brittle hair; decreased hair growth; cold intolerance; slowing of intellectual functioning; lethargy; weight gain; and constipation.
Which action should the nurse take before performing a venipuncture to initiate continuous intravenous (IV) therapy?
- A. Apply a cool compress to the affected area.
- B. Inspect the IV solution and expiration date.
- C. Secure a padded arm board above the IV site.
- D. Apply a tourniquet below the venipuncture site.
Correct Answer: B
Rationale: IV solutions should be free of particles or precipitates to prevent trauma to veins or a thromboembolic event; in addition, the nurse avoids administering IV solutions whose expiration date has passed to prevent infection. Cool compresses cause vasoconstriction, making the vein less visible, smaller, and more difficult to puncture. Arm boards are applied after the IV is started and are used only if necessary. A tourniquet is applied above the chosen vein site to halt venous return and engorge the vein; this makes the vein easier to puncture.
A child hospitalized with a diagnosis of lead poisoning is prescribed chelation therapy. The nurse caring for the child should prepare to administer which medication?
- A. Ipecac syrup
- B. Activated charcoal
- C. Sodium bicarbonate
- D. Calcium disodium edetate (EDTA)
Correct Answer: D
Rationale: EDTA is a chelating agent that is used to treat lead poisoning. Ipecac syrup may be prescribed by the primary health care provider for use in the hospital setting but would not be used to treat lead poisoning. Activated charcoal is used to decrease absorption in certain poisoning situations. Sodium bicarbonate may be used in salicylate poisoning.
The nurse prepares the client for the removal of a nasogastric tube. During the tube removal, the nurse instructs the client to take which action?
- A. Inhale deeply.
- B. Exhale slowly.
- C. Hold in a deep breath.
- D. Pause between breaths.
Correct Answer: C
Rationale: Just before removing the tube, the client is asked to take a deep breath and hold it because breath-holding minimizes the risk of aspirating gastric contents spilled from the tube during removal. The maneuver partially occludes the airway during tube removal; afterward, the client exhales as soon as the tube is out and thus avoids drawing the gastric contents into the trachea.
The nurse is performing a prenatal examination on a client in the third trimester. The nurse begins an abdominal examination that includes Leopold maneuvers. What information should the nurse be able to determine after performing the assessment's first maneuver?
- A. Fetal descent
- B. Placenta previa
- C. Fetal lie and presentation
- D. Strength of uterine contractions
Correct Answer: C
Rationale: The first maneuver, the fundal grip, determines the contents (size, consistency, shape, and mobility) of the fundus (either the fetal head or breech) and thereby the fetal lie. Fetal descent is determined with the fourth maneuver. Placenta previa is diagnosed by ultrasound and not by palpation. Leopold maneuvers are not performed during a contraction.