Nokea
A client with lymphoma reports severe abdominal pain and distension. The nurse suspects tumor lysis syndrome (TLS). Which laboratory result would confirm this diagnosis?
- A. Serum potassium of 6.2 mEq/L.
- B. Serum sodium of 140 mEq/L.
- C. Serum calcium of 9.0 mg/dL.
- D. Serum glucose of 110 mg/dL.
Correct Answer: A
Rationale: TLS causes rapid cell breakdown, releasing potassium, leading to hyperkalemia (potassium >5.5 mEq/L), which confirms the diagnosis and requires urgent management.
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The client's serum potassium level is elevated in acute renal failure, and the nurse administers sodium polystyrene sulfonate (Kayexalate). This drug acts to:
- A. Increase potassium excretion from the colon.
- B. Release hydrogen ions for sodium ions.
- C. Increase calcium absorption in the colon.
- D. Exchange sodium for potassium ions in the colon.
Correct Answer: D
Rationale: Kayexalate exchanges sodium for potassium in the colon, reducing serum potassium levels in acute renal failure.
The client attends two sessions with the dietitian to learn about diet modifications to minimize gastroesophageal reflux. The teaching would be considered successful if the client says that she will decrease her intake of which of the following foods?
- A. Fats.
- B. High-sodium foods.
- C. Carbohydrates.
- D. High-calcium foods.
Correct Answer: A
Rationale: Decreasing fat intake is key to managing GERD, as fatty foods relax the lower esophageal sphincter and delay gastric emptying, worsening reflux.
A client who had received 25 mL of packed red blood cells (PRBCs) has low back pain and pruritus. After stopping the infusion, the nurse should take what action next?
- A. Administer prescribed antihistamine and aspirin.
- B. Collect blood and urine samples and send to the lab.
- C. Administer prescribed diuretics.
- D. Administer prescribed vasopressors.
Correct Answer: B
Rationale: Low back pain and pruritus after 25 mL of PRBCs suggest a transfusion reaction, likely hemolytic or allergic. After stopping the infusion, the nurse should collect blood and urine samples to assess for hemolysis (e.g., free hemoglobin in plasma or urine). Antihistamines may be administered later for allergic symptoms, but lab samples are the priority. Diuretics and vasopressors are not indicated.
When teaching about prevention of infection to a client with a long-term venous catheter, the nurse can document that the client has understood discharge instructions when the client states which of the following?
- A. I will not remove the dressing until I return to the clinic next week.
- B. My husband or I will do the dressing changes three times per week, exactly the way you showed us.
- C. I will monitor my temperature once each weekday.
- D. I know it is very important to wash my hands after irrigating the catheter.
Correct Answer: B
Rationale: Regular dressing changes (three times per week) performed correctly indicate understanding of infection prevention for a long-term venous catheter.
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.