A client with a new diagnosis of myasthenia gravis is prescribed pyridostigmine (Mestinon). Which instruction should the nurse include in the client's teaching?
- A. Take the medication with food to prevent gastrointestinal upset.
- B. Take the medication 30 minutes before meals.
- C. Avoid dairy products while taking this medication.
- D. Take the medication at bedtime.
Correct Answer: B
Rationale: The correct answer is B: Take the medication 30 minutes before meals. Pyridostigmine is a cholinesterase inhibitor used to treat myasthenia gravis by improving muscle strength. Taking it before meals helps optimize its effects when muscle strength is needed the most during eating. Taking it with food (A) may delay absorption. Avoiding dairy products (C) is not necessary with pyridostigmine. Taking the medication at bedtime (D) may not be optimal for addressing muscle weakness during meal times.
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A client with acute pancreatitis is experiencing severe abdominal pain. Which enzyme level should the nurse monitor closely?
- A. Serum amylase.
- B. Serum sodium.
- C. Serum calcium.
- D. Serum potassium.
Correct Answer: A
Rationale: The correct answer is A: Serum amylase. In acute pancreatitis, damaged pancreatic cells release amylase into the bloodstream, causing elevated serum amylase levels. Monitoring serum amylase helps in diagnosing and assessing the severity of pancreatitis.
Incorrect choices:
B: Serum sodium - Serum sodium levels are typically not directly affected by pancreatitis.
C: Serum calcium - While hypocalcemia can occur in severe pancreatitis, monitoring serum calcium is not as specific for pancreatitis diagnosis or severity assessment as serum amylase.
D: Serum potassium - Potassium levels may be affected in pancreatitis due to vomiting or dehydration, but monitoring serum potassium is not as specific to pancreatitis as serum amylase.
The healthcare provider is caring for a client who has just undergone a thyroidectomy. Which assessment finding requires immediate intervention?
- A. Hoarse voice.
- B. Difficulty swallowing.
- C. Numbness and tingling around the mouth.
- D. Sore throat.
Correct Answer: C
Rationale: The correct answer is C: Numbness and tingling around the mouth. This finding indicates potential hypocalcemia, a common complication post-thyroidectomy due to inadvertent removal of parathyroid glands. Immediate intervention is necessary to prevent severe hypocalcemia symptoms like tetany and seizures. Hoarse voice (A) and difficulty swallowing (B) are expected post-thyroidectomy due to surgical trauma, while sore throat (D) is common from intubation.
A client is admitted with diabetic ketoacidosis (DKA). Which assessment finding requires immediate intervention?
- A. Fruity breath odor.
- B. Blood glucose of 450 mg/dL.
- C. Deep, rapid respirations.
- D. Serum potassium of 5.2 mEq/L.
Correct Answer: C
Rationale: Step-by-step rationale:
1. Deep, rapid respirations in DKA indicate Kussmaul respirations, a compensatory mechanism for metabolic acidosis.
2. Immediate intervention is needed to prevent respiratory failure and further acidosis.
3. Administering IV fluids and insulin can help correct acidosis and stabilize breathing.
4. Fruity breath odor (A) and high blood glucose (B) are common in DKA but do not require immediate intervention.
5. Serum potassium of 5.2 mEq/L (D) is slightly elevated but not as urgent as addressing respiratory distress.
A client with liver cirrhosis is prescribed lactulose. What is the purpose of this medication?
- A. To lower blood sugar levels
- B. To reduce ammonia levels
- C. To treat liver inflammation
- D. To improve bile flow
Correct Answer: B
Rationale: Rationale: Lactulose is prescribed for liver cirrhosis to reduce ammonia levels. It works by promoting the excretion of ammonia in the stool, preventing its accumulation in the bloodstream. This helps prevent hepatic encephalopathy, a serious complication of cirrhosis. Other choices are incorrect because lactulose does not directly affect blood sugar levels, liver inflammation, or bile flow in the context of liver cirrhosis.
What side effect should be monitored for in a patient with chronic heart failure taking spironolactone?
- A. Hypokalemia
- B. Hyperkalemia
- C. Hyponatremia
- D. Hypernatremia
Correct Answer: B
Rationale: The correct answer is B: Hyperkalemia. Spironolactone is a potassium-sparing diuretic commonly used in patients with heart failure. It works by blocking the aldosterone receptor, leading to potassium retention and potential hyperkalemia. Monitoring potassium levels is crucial as hyperkalemia can increase the risk of arrhythmias and other cardiac complications in heart failure patients.
A: Hypokalemia is incorrect because spironolactone typically causes potassium retention.
C: Hyponatremia and D: Hypernatremia are incorrect as spironolactone does not directly affect sodium levels.
In summary, monitoring for hyperkalemia is essential in patients with heart failure taking spironolactone to prevent adverse cardiac events.