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A client diagnosed with myasthenia gravis is experiencing prolonged periods of weakness, and the primary health care provider prescribes an edrophonium test, also known as a Tensilon test. A test dose is administered and the client becomes weaker. How should the nurse interpret these results?
- A. Myasthenic crisis is present.
- B. Cholinergic crisis is present.
- C. This result is a normal finding.
- D. This result is a positive finding.
Correct Answer: B
Rationale: An edrophonium test may be performed to determine whether increasing weakness in a client with previously diagnosed myasthenic is a result of cholinergic crisis (overmedication) with anticholinesterase medications or myasthenic crisis (undermedication). Worsening of the symptoms after the test dose of medication is administered indicates a cholinergic crisis.
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The nurse is caring for a client who is receiving total parenteral nutrition and has a prescription for an intravenous intralipid infusion. What intervention should the nurse implement before hanging the intralipid infusion?
- A. Refrigerate the bottle of solution.
- B. Add 100 mL normal saline to the infusion bottle.
- C. Place an in-line filter on the administration tubing.
- D. Check the solution for separation or an oily residue.
Correct Answer: D
Rationale: Intralipids provide nonprotein calories and prevent or correct fatty acid deficiency. The nurse checks the solution for separation or an oily appearance because this can indicate a spoiled or contaminated solution. Refrigeration renders the intralipid solution too thick to administer. Because they can affect the stability of the solution, the nurse avoids injecting additives into the intralipid infusion. Furthermore, an in-line filter is not used because it can disrupt the flow of solution by becoming clogged.
The nurse provides discharge instructions to a client who is recovering from testicular cancer surgery. Which instruction should the nurse include?
- A. To avoid driving a car for at least 2 weeks
- B. Not to be fitted for a prosthesis for at least 3 months
- C. To avoid sitting for long periods for at least 2 weeks
- D. To report any elevation in temperature to the primary health care provider
Correct Answer: D
Rationale: For the client who has had testicular surgery, the nurse should emphasize the importance of notifying the primary health care provider if chills, fever, drainage, redness, or discharge occurs. These symptoms may indicate the presence of an infection. One week after testicular surgery, the client may drive. Often, a prosthesis is inserted during surgery. Sitting needs to be avoided with prostate surgery because of the risk of hemorrhage, but this risk is not as high with testicular surgery.
The nurse suspects that an air embolism has occurred when the client's central venous catheter disconnects from the intravenous (IV) tubing. The nurse immediately places the client on her or his left side in which position?
- A. High Fowler's
- B. Trendelenburg's
- C. Lateral recumbent
- D. Reverse Trendelenburg's
Correct Answer: B
Rationale: If the client develops an air embolism, the immediate action is to place the client in Trendelenburg's position on the left side. This position raises the client's feet higher than the head and traps any air in the right atrium. If necessary, the air can then be directly removed by intracardiac aspiration.
A client is diagnosed with diabetes insipidus. The nurse should plan interventions to address which manifestations of this disorder? Select all that apply.
- A. Bradycardia
- B. Hypertension
- C. Poor skin turgor
- D. Increased urinary output
- E. Dry mucous membranes
- F. Decreased pulse pressure
Correct Answer: C,D,E,F
Rationale: Diabetes insipidus is a water metabolism problem caused by an antidiuretic hormone (ADH) deficiency (either a decrease in ADH synthesis or an inability of the kidneys to respond to ADH). Clinical manifestations include poor skin turgor, increased urinary output, dry mucous membranes, decreased pulse pressure, tachycardia, hypotension, weak peripheral pulses, and increased thirst.
A client seeks treatment in an ambulatory clinic for hoarseness that has persisted for 8 weeks. Based on the symptom, the nurse interprets that the client is at risk for which disorder?
- A. Thyroid cancer
- B. Acute laryngitis
- C. Laryngeal cancer
- D. Bronchogenic cancer
Correct Answer: C
Rationale: Hoarseness is a common early sign of laryngeal cancer, but not of thyroid or bronchogenic cancer. Hoarseness that persists for 8 weeks is not associated with an acute problem, such as laryngitis.