Nokea
A client with suspected Addison's disease is scheduled for a rapid corticotrophin stimulation test. Which of the following will the nurse include in her teaching?
- A. The need to limit fluid intake
- B. The need for periodic blood samples
- C. The need for collection of a 24-hour urine
- D. The need for frequent IV injections
Correct Answer: B
Rationale: The rapid corticotrophin stimulation test requires periodic blood samples to measure cortisol levels before and after ACTH administration.
You may also like to solve these questions
After abdominal surgery, a client has a nasogastric tube attached to low suctioning.
- A. What is the most appropriate nursing intervention for a client with a nasogastric tube who becomes nauseated with decreased gastric secretion flow?
- B. Irrigate the nasogastric tube with distilled water.
- C. Aspirate the gastric contents with a syringe.
- D. Administer an antiemetic medicine.
- E. Insert a new nasogastric tube.
Correct Answer: B
Rationale: Nausea and decreased flow suggest possible NG tube obstruction. Aspirating gastric contents with a syringe confirms tube placement (pH 0-4) and checks for blockages, addressing the cause of symptoms. Irrigation should use normal saline after placement confirmation, and antiemetics or tube replacement do not assess tube function.
A client is given morphine 6 mg IV push for postoperative pain.
- A. What is the most appropriate nursing action for a client with pulse 68, respirations 8, BP 100/68, and sleeping quietly after receiving morphine 6 mg IV?
- B. Allow the client to sleep undisturbed.
- C. Administer oxygen via facemask or nasal prongs.
- D. Administer naloxone (Narcan).
- E. Place epinephrine 1:1,000 at the bedside.
Correct Answer: C
Rationale: A respiratory rate of 8 indicates respiratory depression, a serious side effect of morphine. Administering naloxone (Narcan) is the most appropriate action to reverse this effect. Allowing the client to sleep risks further respiratory compromise, oxygen may be used after naloxone, and epinephrine is not indicated.
Which of the following laboratory results would suggest to the emergency room nurse that a client admitted after a severe motor vehicle crash is in acidosis?
- A. Hemoglobin 15 gm/dl
- B. Chloride 100 mEq/L
- C. Sodium 130 mEq/L
- D. Carbon dioxide 20 mEq/L
Correct Answer: D
Rationale: Serum carbon dioxide is an indicator of acid-base status. This finding would indicate acidosis.
The nurse is monitoring the fluid status of a 63-year-old woman receiving IV fluids following surgery.
- A. Which symptoms suggest fluid volume overload in a 63-year-old woman receiving IV fluids post-surgery?
- B. Temperature 101°F (3°C), BP 96/60, pulse 96 and thready.
- C. Cool skin, respiratory crackles, pulse 86 and bounding.
- D. Complaints of a headache, abdominal pain, and lethargy.
- E. Urinary output 700 cc/24h, CVP of 5, and nystagmus.
Correct Answer: B
Rationale: Fluid volume overload is characterized by symptoms such as a bounding pulse, elevated blood pressure, respiratory crackles (due to pulmonary edema), and distended neck veins. Cool skin and respiratory crackles with a bounding pulse are indicative of this condition. The other options suggest dehydration, non-specific symptoms, or normal findings unrelated to fluid overload.
A child in Bryant's traction. The nurse notes that the foot of the uninjured leg feels warmer to touch than that of the broken leg during neurovascular assessment.
The nurse should
- A. record the observation.
- B. encourage the child to move the foot.
- C. cover the colder foot with a sock.
- D. notify the physician.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) ignores possibility that Ace bandage is too tight (2) does not relieve the circulation problem (3) does not relieve the circulation problem (4) correct-assessment indicates that Ace bandage is too tight and needs readjusting