Nokea
A client's serum ammonia level is elevated, and the physician orders 30 mL of lactulose (Cephulac). Which of the following is an adverse effect of this drug?
- A. Increased urine output.
- B. Improved level of consciousness.
- C. Increased bowel movements.
- D. Nausea and vomiting.
Correct Answer: C
Rationale: Lactulose promotes bowel movements (C) to excrete ammonia, a common adverse effect. Urine output (A) and consciousness (B) are not adverse effects. Nausea (D) is less common.
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The nurse receives emergency laboratory results for a client with chest pain and immediately informs the physician. An increased myoglobin level suggests which of the following?
- A. Cancer.
- B. Hypertension.
- C. Liver disease.
- D. Myocardial damage.
Correct Answer: D
Rationale: Elevated myoglobin indicates myocardial damage, as it is released from injured cardiac muscle, supporting a diagnosis of MI.
A nurse assesses a 40-year-old female client with vasospastic disorder (Raynaud's phenomenon) involving her right hand. The nurse notes the information in the progress notes, as shown below. From these findings, the nurse should formulate which priority nursing diagnosis?
- A. Acute pain related to hyperemic stage
- B. Disturbed sensory perception (tactile) related to vasospastic process
- C. Ineffective tissue perfusion (peripheral) related to vasospastic process
- D. Risk for impaired skin integrity related to vasospastic process
Correct Answer: C
Rationale: Ineffective tissue perfusion (peripheral) is the priority nursing diagnosis in Raynaud's phenomenon, as vasospasm reduces blood flow to the extremities, causing ischemia. This underlies symptoms like numbness or pallor. Pain, sensory changes, or skin integrity risks are secondary to perfusion deficits.
A short time after cataract surgery, the client complains of nausea. The nurse should first:
- A. Instruct the client to take a few deep breaths until the nausea subsides.
- B. Explain that this is a common feeling that will pass quickly.
- C. Tell the client to call the nurse promptly if vomiting occurs.
- D. Administer an antiemetic, as ordered.
Correct Answer: D
Rationale: Nausea after cataract surgery can indicate increased intraocular pressure or other complications. Administering an antiemetic as ordered is the priority to prevent vomiting, which could increase intraocular pressure and cause complications.
The nurse teaches a client about using the crutches, instructing the client to support her weight primarily on which of the following body areas?
- A. Axillae.
- B. Elbows.
- C. Upper arms.
- D. Hands.
Correct Answer: D
Rationale: Weight should be supported on the hands to prevent nerve damage in the axillae.
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.