Nokea
A client with thyrotoxicosis says to the nurse, 'I am so irritable. I am having problems at work because I lose my temper very easily.' Which of the following responses by the nurse would give the client the most accurate explanation of her behavior?
- A. Your behavior is caused by your not following the medical regimen.'
- B. Your behavior is caused by the effects of the disease on your thyroid.'
- C. Your behavior is caused by your not accepting your diagnosis.'
- D. Your behavior is caused by the effects of the disease on your emotional stability.'
Correct Answer: B
Rationale: Thyrotoxicosis, due to excess thyroid hormone, increases metabolism and can affect the nervous system, leading to irritability and emotional lability. This explains the client's behavior as a direct result of the disease's impact on thyroid function.
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When caring for the client who is receiving an aminoglycoside antibiotic, the nurse should monitor which of the following laboratory values?
- A. Serum sodium.
- B. Serum potassium.
- C. Serum creatinine.
- D. Serum calcium.
Correct Answer: C
Rationale: Aminoglycosides are nephrotoxic; monitoring serum creatinine assesses kidney function. Sodium, potassium, and calcium are not primarily affected by aminoglycosides.
The nurse is reviewing acetaminophen (APAP) toxicity with students. The nurse should remind students that the maximum acetaminophen dosage for an adult is
- A. 2,000 mg per day
- B. 4,000 mg per day
- C. 5,000 mg per day
- D. 6,000 mg per day
Correct Answer: B
Rationale: The maximum recommended adult dose of acetaminophen is 4,000 mg per day to avoid liver toxicity.
The nurse monitors a client with cirrhosis for the development of hepatic encephalopathy. Which of the following would be an indication that hepatic encephalopathy is developing?
- A. Decreased mental status.
- B. Elevated blood pressure.
- C. Decreased urine output.
- D. Labored respirations.
Correct Answer: A
Rationale: Hepatic encephalopathy causes decreased mental status (A) due to ammonia buildup. Elevated blood pressure (B), decreased urine output (C), and labored respirations (D) are not primary indicators.
Which safety measures would be most important to implement when caring for a client who is receiving 2 units of packed red blood cells (PRBCs)? Select all that apply.
- A. Verify that the ABO and Rh of the 2 units are the same.
- B. Infuse the unit of PRBCs in less than 4 hours.
- C. Stop the transfusion if a reaction occurs, but keep the line open.
- D. Take vital signs every 15 minutes while the unit is transfusing.
- E. Inspect the blood bag for leaks, abnormal color, and clots.
- F. Use a 22-gauge catheter for optimal flow of a blood transfusion.
Correct Answer: A,B,C,E
Rationale: Key safety measures for PRBC transfusion include verifying ABO and Rh compatibility to prevent reactions, infusing within 4 hours to reduce infection risk, stopping the transfusion if a reaction occurs while keeping the line open, and inspecting the blood bag for abnormalities. Taking vital signs every 15 minutes is excessive (typically every 15 minutes for the first 15 minutes, then hourly). A 22-gauge catheter is too small; a larger gauge (18–20) is needed for optimal flow.
A client with chest pain is prescribed intravenous nitroglycerin (Tridil). Which assessment is of greatest concern for the nurse initiating the nitroglycerin drip?
- A. Serum potassium is 3.5 mEq/L.
- B. Blood pressure is 88/46.
- C. ST elevation is present on the electrocardiogram.
- D. Heart rate is 61.
Correct Answer: B
Rationale: Nitroglycerin causes vasodilation, which can lower blood pressure. A blood pressure of 88/46 indicates hypotension, a significant concern as it may compromise perfusion, making it the priority assessment.