Nokea
A client who developed syndrome of inappropriate antidiuretic hormone (SIADH) associated with small carcinoma of the lung is preparing for discharge. When teaching the client about self-management with demeclocycline (Declomycin), the nurse should instruct the client to report which condition to the healthcare provider?
- A. Insomnia
- B. Muscle cramping
- C. Increased appetite
- D. Anxiety
Correct Answer: B
Rationale: The correct answer is B: Muscle cramping. SIADH causes dilutional hyponatremia due to increased ADH release. Demeclocycline is used to block the action of ADH. Muscle cramping can indicate electrolyte imbalances related to hyponatremia, which should be reported to the healthcare provider. Insomnia, increased appetite, and anxiety are not typically associated with the side effects or complications of demeclocycline or SIADH.
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When assessing a client with left-sided heart failure, which intervention should the nurse implement first?
- A. Administer oxygen therapy as prescribed.
- B. Monitor the client's urine output.
- C. Administer a loop diuretic as prescribed.
- D. Administer morphine as prescribed.
Correct Answer: A
Rationale: Administering oxygen therapy is the initial intervention for a client with left-sided heart failure. This action is crucial in improving oxygen levels and reducing pulmonary congestion. Monitoring urine output is important for assessing renal function in heart failure, but it is not the priority over ensuring adequate oxygenation. Administering loop diuretics helps manage fluid overload but should come after addressing oxygen needs. Morphine may be indicated for pain or anxiety in some cases, but it is not the primary intervention for left-sided heart failure.
A newly graduated female staff nurse approaches the nurse manager and requests reassignment to another client because a male client is asking her for a date and making suggestive comments. Which response is best for the nurse manager to provide?
- A. I have to call the supervisor to get someone else to transfer to this unit to care for him.
- B. I know you are a good nurse and can handle this client in a professional manner.
- C. I'll talk to the client about his sexual harassment and insist that he stop immediately.
- D. I'll change your assignment, but let's talk about how a nurse should respond to this kind of client.
Correct Answer: D
Rationale: The best response for the nurse manager is option D. Changing the assignment while providing guidance on professional boundaries and how to handle such situations is essential. Option A is not appropriate as it does not address the issue of the client's behavior. Option B, although supportive, does not offer a solution to the problem at hand. Option C is not the best approach as directly confronting the client about sexual harassment may escalate the situation further.
The nurse is administering an IV medication to a client with a history of anaphylaxis. Which intervention is most important for the nurse to implement?
- A. Stay with the client throughout the infusion.
- B. Keep emergency resuscitation equipment at the bedside.
- C. Obtain the client's allergy history.
- D. Ask the client about past allergic reactions to medications.
Correct Answer: B
Rationale: Keeping emergency resuscitation equipment at the bedside is crucial in case the client experiences anaphylaxis during the infusion. While staying with the client throughout the infusion (Choice A) is important, having immediate access to emergency equipment takes priority in this situation. Obtaining the client's allergy history (Choice C) and asking about past allergic reactions to medications (Choice D) are relevant but do not address the immediate need for emergency intervention in case of anaphylaxis.
A client with a history of atrial fibrillation is prescribed warfarin (Coumadin). Which clinical finding is most concerning?
- A. Headache
- B. Prothrombin time (PT) of 15 seconds
- C. Elevated liver enzymes
- D. Peripheral edema
Correct Answer: A
Rationale: The correct answer is A: Headache. In a client with atrial fibrillation taking warfarin (Coumadin), a headache can be indicative of bleeding, which is a serious complication requiring immediate assessment and intervention. Monitoring for signs of bleeding is crucial when on anticoagulant therapy. Choices B, C, and D are not the most concerning. A prothrombin time of 15 seconds is within the therapeutic range for a client on warfarin, elevated liver enzymes may indicate liver dysfunction but are not directly related to the medication's side effects, and peripheral edema is not typically associated with warfarin use or atrial fibrillation in this context.
The nurse is reinforcing home care instructions with a client who is being discharged following a transurethral resection of the prostate (TURP). Which intervention is most important for the nurse to include in the client teaching?
- A. Avoid strenuous activity for 6 weeks.
- B. Report fresh blood in the urine.
- C. Take acetaminophen for a fever over 101°F.
- D. Consume 6 to 8 glasses of water daily.
Correct Answer: B
Rationale: Reporting fresh blood in the urine is crucial as it may indicate postoperative complications requiring immediate attention. This symptom can be a sign of bleeding, infection, or other issues that need prompt medical evaluation. Avoiding strenuous activity for 6 weeks is important but not as urgent as reporting fresh blood. Taking acetaminophen for a fever over 101°F is relevant but addressing fresh blood in the urine takes precedence. Consuming an adequate amount of water daily is beneficial but not as critical as recognizing and reporting signs of potential complications.