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A client with Addison's disease is being admitted for a total hip arthroplasty. The client takes hydrocortisone. What is the nurse's priority action?
- A. Administering a supplemental dose of hydrocortisone
- B. Instructing the client about coughing and deep breathing
- C. Collecting additional information from the client about his history of Addison's disease
- D. Inserting an indwelling urinary catheter
Correct Answer: A
Rationale: The priority action for a client with Addison's disease undergoing surgery who takes hydrocortisone is to administer a supplemental dose of hydrocortisone. Acute adrenal insufficiency (adrenal crisis) is a significant risk during surgery due to the stress placed on the body. Supplemental doses help prevent acute adrenal insufficiency and ensure the client's safety during the surgical procedure. Instructing the client about coughing and deep breathing is important post-operatively but not the priority before surgery. Collecting additional information about the client's history of Addison's disease is relevant but not the priority action before surgery. Inserting an indwelling urinary catheter is not the priority action in this scenario.
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A healthcare professional is preparing to administer a transfusion of 300 mL of pooled platelets for a client who has severe Thrombocytopenia. How long should the healthcare professional plan to administer the transfusion over?
- A. Within 30 min/unit
- B. Within 60 min/unit
- C. Within 2 hr/unit
- D. Within 4 hr/unit
Correct Answer: A
Rationale: Platelets are fragile components that must be administered quickly to maintain their effectiveness and minimize the risk of clumping. The recommended administration time for platelets is within 15 to 30 minutes per unit. This rapid administration helps ensure the platelets remain viable and functional for the client receiving the transfusion. Therefore, the correct answer is to administer the transfusion within 30 minutes per unit. Choices B, C, and D are incorrect as they exceed the recommended administration time for platelets, which could compromise their efficacy and pose risks to the client.
A healthcare professional is reviewing a client's medication history and notes a new prescription for Enalapril. The healthcare professional should monitor the client for which of the following as an adverse effect of this medication?
- A. Bradycardia
- B. Hyperkalemia
- C. Hypoglycemia
- D. Hypocalcemia
Correct Answer: B
Rationale: Enalapril, an ACE inhibitor, can cause hyperkalemia as an adverse effect due to decreased aldosterone levels, which leads to potassium retention. Monitoring potassium levels is essential to prevent potential complications associated with hyperkalemia. The other options, bradycardia, hypoglycemia, and hypocalcemia, are not typically associated with Enalapril use and are less likely to occur as adverse effects.
A client has a prescription for Nitroglycerin, and a nurse is providing teaching. Which of the following instructions should the nurse include?
- A. Take one tablet every 15 minutes until pain is relieved.
- B. Take one tablet every 5 minutes, up to three doses.
- C. Take one tablet at bedtime.
- D. Take one tablet on an empty stomach.
Correct Answer: B
Rationale: The correct instruction for taking Nitroglycerin is to take one tablet at the onset of chest pain, then repeat every 5 minutes for up to three doses. Option A is incorrect because taking a tablet every 15 minutes until pain is relieved may lead to delayed intervention. Option C is incorrect as taking Nitroglycerin at bedtime is not indicated for chest pain. Option D is incorrect as Nitroglycerin should be taken sublingually at the onset of chest pain, not on an empty stomach.
When teaching a client with a prescription for long-term use of oral prednisone for chronic asthma, the nurse should instruct the client to monitor for which of the following adverse effects of this medication?
- A. Weight gain
- B. Nervousness
- C. Bradycardia
- D. Constipation
Correct Answer: A
Rationale: The correct answer is weight gain. Weight gain and fluid retention are common adverse effects of oral prednisone due to sodium and water retention. Patients on long-term prednisone therapy should be advised to monitor their weight closely and report any significant changes to their healthcare provider. Choice B, 'Nervousness,' is not typically associated with oral prednisone use. Choice C, 'Bradycardia,' refers to a slow heart rate, which is not a common adverse effect of prednisone. Choice D, 'Constipation,' is not a typical adverse effect of oral prednisone; instead, gastrointestinal disturbances like increased appetite or even peptic ulcer disease may occur.
A healthcare provider is preparing to administer an IV bolus of Morphine to a client for pain management. Which of the following assessments is the healthcare provider's priority?
- A. Respiratory rate
- B. Pain level
- C. Blood pressure
- D. Level of consciousness
Correct Answer: A
Rationale: The priority assessment for a healthcare provider preparing to administer an IV bolus of Morphine is the client's respiratory rate. Morphine can cause respiratory depression as a significant adverse effect, so monitoring the respiratory rate is crucial to detect any signs of respiratory compromise and intervene promptly. Assessing the respiratory rate takes precedence over other assessments because respiratory depression can lead to serious complications. While pain level, blood pressure, and level of consciousness are important assessments, they are not the priority when administering Morphine, as the risk of respiratory depression is a more immediate concern.