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A client with primary diabetes insipidus is ready for discharge on desmopressin (DDAVP). Which instruction should the nurse provide?
- A. “Administer desmopressin while the suspension is cold.”
- B. “Your condition isn’t chronic, so you won’t need to wear a medical identification bracelet.”
- C. “You may not be able to use desmopressin nasally if you have nasal discharge or blockage.”
- D. “You won’t need to monitor your fluid intake and output after you start taking desmopressin.”
Correct Answer: C
Rationale: The correct answer is C: “You may not be able to use desmopressin nasally if you have nasal discharge or blockage.”
Rationale:
1. Desmopressin is available in intranasal form for diabetes insipidus.
2. Nasal discharge or blockage may prevent proper absorption of the medication.
3. Instructing the client about this potential issue ensures optimal drug effectiveness.
Summary:
A: Incorrect. Temperature of desmopressin suspension doesn't affect its efficacy.
B: Incorrect. A medical identification bracelet is necessary for chronic conditions like diabetes insipidus.
D: Incorrect. Monitoring fluid intake and output is crucial when taking desmopressin.
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Maintaining the infusion rate of hyperalimentation solutions is a nursing responsibility. What side effects would you anticipate from too rapid infusion rate?
- A. Cellular dehydration and potassium
- B. Hypoglycemia and hypovolemia
- C. Potassium excess and CHF
- D. Circulatory overload and hypoglycemia SITUATION: In the recall of the fluids and electrolytes, the nurse should be able to understand the calculations and other conditions related to loss or retention.
Correct Answer: D
Rationale: Rationale:
1. Rapid infusion of hyperalimentation solutions can lead to circulatory overload due to increased fluid volume in the circulatory system.
2. Circulatory overload can result in symptoms such as hypertension, tachycardia, and edema.
3. Hypoglycemia can occur as a result of excess insulin release due to the sudden increase in glucose from the hyperalimentation solution.
Summary:
A. Cellular dehydration and potassium: Incorrect. Rapid infusion would lead to fluid overload, not dehydration.
B. Hypoglycemia and hypovolemia: Incorrect. Hypovolemia is unlikely with rapid infusion, and hypoglycemia is a possible side effect.
C. Potassium excess and CHF: Incorrect. Rapid infusion may cause circulatory overload, not CHF, and potassium excess is not a common side effect.
D. Circulatory overload and hypoglycemia: Correct. These are the most likely side effects of rapid
The nurse recognizes that the major early problem for Mr. Gabatan will be:
- A. Bladder control
- B. Quadriceps setting
- C. Client education
- D. Use of aids for ambulation
Correct Answer: B
Rationale: The correct answer is B: Quadriceps setting. After surgery, quadriceps setting exercises are crucial for preventing muscle atrophy and maintaining joint mobility. Bladder control (A) is important but typically not the major early problem. Client education (C) and use of aids for ambulation (D) are important aspects of care but not the primary concern immediately post-surgery. Quadriceps setting helps prevent complications and promote early mobility.
Aling Nena, 68 years old, had a MVA and underwent surgery for hip fracture. Two days post-surgery, she suddenly complained of chest heaviness despite the absence of cardiac history. What is the nursing priority?
- A. document the onset, duration, severity, and precipitating factors
- B. may offer analgesics for chest pain
- C. administer oxygen via face mask
- D. inform the physician about the heaviness
Correct Answer: C
Rationale: The correct answer is C: administer oxygen via face mask. Given Aling Nena's sudden chest heaviness post-surgery, oxygen administration is the priority to ensure adequate oxygenation. This can help rule out potential respiratory issues or hypoxemia, which are common post-operatively. Providing oxygen promptly can prevent further complications such as respiratory distress or cardiac compromise. Documenting the pain characteristics (choice A) can be done after ensuring immediate physiological needs are met. Offering analgesics (choice B) without confirming the underlying cause can mask symptoms and delay appropriate interventions. Informing the physician (choice D) is important but not as urgent as addressing potential respiratory compromise.
A client has undergone a nephrectomy and is placed under observation after a urethral catheter insertion. As part of the nursing care plan, the nurse records the color of drainage from each tube and catheter. Which of the ff is the reason for this?
- A. To restore and maintain intravascular volume
- B. To provide a means for further comparison and evaluation
- C. To avoid interference with wound drainage
- D. To prevent pain related to obstruction
Correct Answer: B
Rationale: The correct answer is B: To provide a means for further comparison and evaluation. By recording the color of drainage from each tube and catheter, the nurse can monitor changes over time, assess for any abnormalities, and evaluate the effectiveness of treatment. This helps in detecting complications early and making informed decisions.
Rationale for other choices:
A: To restore and maintain intravascular volume - Monitoring drainage color does not directly relate to intravascular volume status.
C: To avoid interference with wound drainage - Monitoring drainage color does not prevent interference with wound drainage.
D: To prevent pain related to obstruction - Monitoring drainage color does not directly prevent pain related to obstruction.
For a client with an exacerbation of rheumatoid arthritis, the physician prescribes the corticosteroid prednisone (Deltasone). When caring for this client, the nurse should monitor for which adverse drug reactions?
- A. Increased weight, hypertension, and insomnia
- B. Vaginal bleeding, jaundice, and inflammation
- C. Stupor, breast lumps, and pain
- D. Dyspnea, numbness, and headache
Correct Answer: A
Rationale: The correct answer is A. Prednisone is a corticosteroid that can cause adverse reactions such as increased weight due to fluid retention, hypertension due to sodium retention, and insomnia due to its stimulating effects. Vaginal bleeding, jaundice, inflammation, stupor, breast lumps, pain, dyspnea, numbness, and headache are not commonly associated with prednisone use. Monitoring for weight changes, blood pressure, and sleep patterns is essential when administering prednisone to a client with rheumatoid arthritis for early detection and management of adverse reactions.