Nokea
A client with cirrhosis is taking lactulose (Cephulac). Which finding indicates that the lactulose is having the desired effect?
- A. Two to three soft bowel movements per day
- B. Increased serum ammonia levels
- C. Decreased white blood cell count
- D. Soft, formed stool twice a day
Correct Answer: A
Rationale: The correct answer is A: 'Two to three soft bowel movements per day.' Lactulose is prescribed to produce soft, regular bowel movements to reduce ammonia levels in clients with cirrhosis. This helps in preventing hepatic encephalopathy. Option B is incorrect because increased serum ammonia levels would indicate that lactulose is not effectively reducing ammonia levels. Option C is incorrect because lactulose does not directly affect white blood cell counts. Option D is incorrect because soft, formed stools twice a day may not be frequent enough to effectively reduce ammonia levels in clients with cirrhosis.
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The nurse is preparing to administer the 0800 dose of 20 units of Humulin R to an 8-year-old girl diagnosed with Type 1 diabetes. The mother comments that her daughter is a very picky eater and many times does not eat meals. Which intervention should the nurse implement first?
- A. Administer the 20 Units of Humulin R subcutaneously as prescribed
- B. Ask the girl if she will be eating her breakfast this morning
- C. Discuss changing the insulin prescription to Lispro with the healthcare provider
- D. Explain to the mother the importance of eating the scheduled meals
Correct Answer: B
Rationale: The correct answer is to ask the girl if she will be eating her breakfast this morning. This is important to determine if the child will be consuming food, which is crucial information before administering insulin. If the child does not plan to eat, administering the full dose of insulin may lead to hypoglycemia. Choice A is incorrect as administering the insulin without knowing if the child will eat can be dangerous. Choice C is not the first intervention because the immediate concern is the child's meal intake. Choice D, while important, is not the first step in this situation.
A male client with hypertension tells the nurse that he is going to take ginseng to increase his stamina. What information should the nurse provide this client?
- A. Ginseng can decrease the effectiveness of your blood pressure medication
- B. You will need to stop taking ginseng while on blood pressure medication
- C. It is important to monitor your blood pressure regularly while taking ginseng
- D. Ginseng can increase your blood pressure
Correct Answer: D
Rationale: The correct answer is D: "Ginseng can increase blood pressure, which is a concern for clients with hypertension." Choice A is incorrect because ginseng does not typically decrease the effectiveness of blood pressure medication. Choice B is incorrect as stopping ginseng while on blood pressure medication may not be necessary. Choice C is not the most direct concern related to ginseng use in a hypertensive client, making it less relevant than the correct answer.
A client with diabetes mellitus reports feeling dizzy and has a blood glucose level of 50 mg/dl. What action should the nurse take first?
- A. Administer 1 mg of glucagon intramuscularly
- B. Provide 15 grams of carbohydrate
- C. Check the client's blood pressure
- D. Notify the healthcare provider
Correct Answer: B
Rationale: Providing 15 grams of carbohydrate is the initial action to treat hypoglycemia. When a client with diabetes mellitus experiences symptoms of hypoglycemia, such as dizziness and with a blood glucose level of 50 mg/dl, the immediate priority is to raise their blood sugar levels quickly. Administering carbohydrates, such as fruit juice or glucose tablets, is the recommended first step to reverse hypoglycemia. Administering glucagon intramuscularly is usually reserved for severe hypoglycemia when the client is unconscious or unable to swallow. Checking the client's blood pressure is important but not the primary intervention for hypoglycemia. Notifying the healthcare provider can be done after the immediate management of hypoglycemia.
At a community health fair, a 50-year-old woman tells the nurse that she has an annual physical exam that includes a clinical breast exam and an annual mammogram. How should the nurse respond?
- A. Encourage the woman to explore her fears about breast cancer.
- B. Ask the woman if she also performs monthly breast self-exams.
- C. Commend the woman for adhering to the recommended cancer detection guidelines.
- D. Advise the woman that mammograms are only needed every two years at her age.
Correct Answer: B
Rationale: The correct answer is B. Monthly breast self-exams are essential for early detection of breast cancer. While annual clinical breast exams and mammograms are important, monthly self-exams enhance early detection by helping women become familiar with their breasts and notice any changes. Choice A is incorrect as it does not address the importance of self-exams. Choice C is incorrect as it prematurely commends without ensuring the woman is conducting self-exams. Choice D is incorrect as it provides inaccurate information about the frequency of mammograms needed.
Assessment findings of a 3-hour-old newborn include: axillary temperature of 97.7°F, heart rate of 140 beats/minute with a soft murmur, and irregular respiratory rate at 42 breaths/min. Based on these findings, what action should the nurse implement?
- A. Place a pulse oximeter on the heel
- B. Swaddle the infant in a warm blanket
- C. Record the findings on the flow sheet
- D. Check the vital signs in 15 minutes
Correct Answer: C
Rationale: The correct answer is to record the findings on the flow sheet. These assessment findings are within normal limits for a 3-hour-old newborn. The axillary temperature of 97.7°F, heart rate of 140 beats/minute with a soft murmur, and irregular respiratory rate of 42 breaths/min are all expected in a newborn. No immediate intervention is needed, so the nurse should document these normal findings for future reference. Placing a pulse oximeter on the heel or swaddling the infant in a warm blanket is not indicated as the vital signs are within normal limits. Checking the vital signs in 15 minutes is unnecessary since the current findings are normal.