Nokea
A client with acute renal failure has an increase in the serum potassium level. The nurse should monitor the client for:
- A. Cardiac arrest.
- B. Pulmonary edema.
- C. Circulatory collapse.
- D. Hemorrhage.
Correct Answer: A
Rationale: Elevated potassium can cause cardiac arrhythmias, potentially leading to cardiac arrest, requiring close monitoring.
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A client with Graves' disease is treated with radioactive iodine (RAI) in the form of sodium iodide 131I. Which of the following statements by the nurse will explain to the client how the drug works?
- A. The radioactive iodine stabilizes the thyroid hormone levels before a thyroidectomy.'
- B. The radioactive iodine reduces uptake of thyroxine and thereby improves your condition.'
- C. The radioactive iodine slows your body's production of thyroid hormones.'
- D. The radioactive iodine destroys thyroid tissue and thyroid hormones are no longer produced.'
Correct Answer: D
Rationale: Radioactive iodine (RAI) works by destroying thyroid tissue, which reduces or eliminates the production of thyroid hormones, treating hyperthyroidism in Graves' disease.
If a client is receiving rescue breaths and the chest wall fails to rise during cardiopulmonary resuscitation, the rescuer should first:
- A. Try using an ambu bag.
- B. Decrease the rate of compressions.
- C. Intubate the client.
- D. Reposition the airway.
Correct Answer: D
Rationale: Failure of the chest to rise during rescue breaths suggests airway obstruction or improper positioning. Repositioning the airway (e.g., head-tilt-chin-lift) is the first step.
A 58-year-old male has just had a sclerosing agent instilled after chest tube drainage of a pleural effusion. The nurse should instruct the client to:
- A. Lie still to prevent a pneumothorax.
- B. Sit upright with arms on an overhead table to promote lung expansion.
- C. Change position frequently to distribute the agent.
- D. Lie on the side where the thoracentesis was done to hold pressure on the chest tube site.
Correct Answer: C
Rationale: Changing position frequently distributes the sclerosing agent evenly, promoting effective pleurodesis to prevent recurrent pleural effusion.
The nurse is planning a home visit for a client with hepatitis. In order to prevent transmission the nurse should focus teaching on:
- A. Proper food handling.
- B. Insulin syringe disposal.
- C. Alpha-interferon.
- D. Use of condoms.
Correct Answer: D
Rationale: Hepatitis B and C are transmitted via body fluids, so condom use (D) prevents sexual transmission. Food handling (A) is key for hepatitis A, syringe disposal (B) applies to needle-sharing, and alpha-interferon (C) is a treatment, not a preventive measure.
The nurse is to administer Polycillin (ampicillin) 500 mg orally to a client with a ruptured appendix. The nurse checks the capsule in the client's medication box which is located inside of the client's room. The dosage of the medication is not labeled, but the nurse recognizes the color and shape of the capsule. The nurse should next:
- A. Administer the medication to maintain blood levels of the drug.
- B. Ask another registered nurse to verify that the capsule is ampicillin.
- C. Contact the pharmacy to bring a properly labeled medication.
- D. Adjust the unit manager to report the problem.
Correct Answer: C
Rationale: Contacting the pharmacy to bring a properly labeled medication ensures safe administration, as recognizing the capsule's color and shape is insufficient for verification. Administering without confirmation or relying on another nurse risks error, and reporting to the manager delays care. CN: Safety and infection control; CL: Synthesize