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A client who has small cell carcinoma of the lung is admitted with symptoms of syndrome of inappropriate antidiuretic hormone (SIADH). As the client's serum sodium level increases from 120 mEq/L to 125 mEq/L, which intervention should the nurse implement?
- A. Assess for increasing fluid volume overload.
- B. Withhold next scheduled dose of treatment.
- C. Increase neurologic checks to every 2 hours.
- D. Maintain the prescribed fluid restriction.
Correct Answer: D
Rationale: Maintaining the prescribed fluid restriction is essential to prevent further dilutional hyponatremia and to help normalize the serum sodium level gradually.
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History and Physical
Nurses' Notes
Laboratory Results
The client is a 38-year-old male with a history of type 1 diabetes mellitus. The client was diagnosed at the age of 8. The client reports that he has stopped testing his blood glucose regularly since losing his insurance 4 years ago and has been in the hospital 2 times for diabetic ketoacidosis
A client reports to the clinic nurse of recently experiencing symptoms of frequent urination, hunger, and great thirst. What finding(s) would the nurse consider as most significant to report to the healthcare provider? Select all that apply.
- A. Serum potassium of 4.2 mEq/L.
- B. Hemoglobin A1C 7%.
- C. Total cholesterol 180 mg/dL.
- D. Hematocrit 45%.
- E. Random plasma glucose level 200 mg/dl.
Correct Answer: B,E
Rationale: Hemoglobin A1C of 7% and random plasma glucose of 200 mg/dL indicate poor glycemic control, suggestive of diabetes, requiring immediate reporting.
The nurse is caring for a client who tests positive for the sexually transmitted infection (STI) gonorrhea. The client reports having sex with someone who has many partners. Which response should the nurse provide?
- A. Teach importance of medication regimen and follow-up protocol.
- B. Discuss that partners without similar symptoms may not be infected.
- C. Emphasize that using safe sex practices removes the risk of STIs.
- D. Clarify that all STIs are transmitted through sexual intercourse.
Correct Answer: A
Rationale: Teaching the importance of medication regimen and follow-up protocol is crucial for treating gonorrhea and preventing its spread.
The nurse is caring for a client who reports a sudden, severe headache, and facial numbness. The nurse asks the client to smile and observes an uneven smile with facial droop to the right side and a hand grasp strength that is weaker on the right than the left. The client denies a recent history of headaches or trauma. Which intervention should the nurse perform in the immediate management of the client?
- A. Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.
- B. Administer aspirin to prevent further clot formation and platelet clumping.
- C. Verify prescribed laboratory tests include prothrombin time and platelet count.
- D. Maintain elevated positioning of the dependent joints on affected side.
Correct Answer: A
Rationale: Starting two large bore IV catheters and reviewing criteria for IV fibrinolytic therapy is essential for managing a suspected stroke, enabling time-sensitive interventions.
Which findings during the admission assessment should the nurse document that are related to a client diagnosed with Cushing's syndrome?
- A. Husky voice and troubled by hoarseness.
- B. Central type obesity, with thin extremities.
- C. Warm, soft, moist, salmon colored skin.
- D. Visible swelling of the neck, with no pain.
Correct Answer: B
Rationale: Central type obesity with thin extremities is a classic manifestation of Cushing's syndrome due to excess cortisol, causing fat accumulation in the trunk and muscle wasting in the extremities.
A client receives a prescription for 1 L of lactated Ringers to be infused IV over 8 hours. The IV administration set delivers 15 gtt/mL. How many mL/hr should the nurse program the infusion pump to deliver?
- A. 125
Correct Answer: A
Rationale: To calculate the infusion rate: 1000 mL / 8 hr = 125 mL/hr. The nurse should program the infusion pump to deliver 125 mL/hr.