Nokea
A client with cirrhosis begins to develop ascites. Spironolactone (Aldactone) is prescribed to treat the ascites. The nurse should monitor the client closely for which of the following drug-related adverse effects?
- A. Constipation.
- B. Hyperkalemia.
- C. Irregular pulse.
- D. Dysuria.
Correct Answer: B
Rationale: Spironolactone, a potassium-sparing diuretic, can cause hyperkalemia (B), a critical adverse effect. Constipation (A), irregular pulse (C), and dysuria (D) are not commonly associated.
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A client with Parkinson's disease asks the nurse to explain to his nephew "what the doctor said the pallidotomy would do." The nurse's best response includes stating that the main goal for the client after pallidotomy is improved:
- A. Functional ability.
- B. Emotional stress.
- C. Alertness.
- D. Appetite.
Correct Answer: A
Rationale: Pallidotomy aims to improve functional ability by reducing symptoms like tremors and rigidity. Emotional stress, alertness, and appetite are not primary targets of this procedure.
When teaching a client newly diagnosed with primary Addison's disease, the nurse should explain that the disease results from:
- A. Insufficient secretion of growth hormone (GH).
- B. Dysfunction of the hypothalamic pituitary.
- C. Idiopathic atrophy of the adrenal gland.
- D. Oversecretion of the adrenal medulla.
Correct Answer: C
Rationale: Primary Addison's disease is caused by idiopathic adrenal gland atrophy, leading to deficient cortisol and aldosterone production.
A client is to receive glargine (Lantus) insulin in addition to a dose of aspart (NovoLog). When the nurse checks the blood glucose level at the bedside, it is greater than 200 mg/dL. How should the nurse administer the insulins?
- A. Put air into the glargine insulin vial, and then air into the aspart insulin vial, and draw up the correct dose of aspart insulin first.
- B. Roll the glargine insulin vial, then roll the aspart insulin vial. Draw up the longer-acting glargine insulin first.
- C. Shake both vials of insulin before drawing up each dose in separate insulin syringes.
- D. Add a little air to the glargine insulin vial and draw up the correct dose in an insulin syringe; then, with a different insulin syringe, put air into the aspart vial and draw up the correct dose.
Correct Answer: D
Rationale: Glargine and aspart insulins cannot be mixed. They should be drawn up in separate syringes to maintain their distinct actions (long-acting vs. rapid-acting). Shaking or rolling is inappropriate for glargine, which is clear.
The family members caring for a 72-year-old client who is near death from colon cancer are concerned about dehydration. What should the nurse tell them about dehydration at end of life?
- A. The physician will make the decision regarding hydration therapy.
- B. Dehydration may prolong the dying process.
- C. Hydration is used only in extreme situations of dehydration.
- D. Dehydration is expected during the dying process.
Correct Answer: D
Rationale: Dehydration is a natural part of the dying process and is often not treated aggressively in hospice care, as it may not cause discomfort and can reduce symptoms like edema.
A nurse is assessing a female who is receiving the second administration of chemotherapy for breast cancer. When obtaining this client's health history, what is the most important information the nurse should obtain?
- A. Has your hair been falling out in clumps?
- B. Have you had nausea or vomiting?
- C. Have you been sleeping at night?
- D. Do you have your usual energy level?
Correct Answer: B
Rationale: Nausea and vomiting are critical to assess during chemotherapy, as they can lead to dehydration, malnutrition, and treatment delays if not managed promptly.