Nokea
A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate?
- A. Pantoprazole 80 mg IV bolus twice daily
- B. Furosemide 40 mg IV
- C. Lactulose 20 mg PO
- D. Acetaminophen 650 mg PO
Correct Answer: A
Rationale: The correct answer is A: Pantoprazole 80 mg IV bolus twice daily. In acute pancreatitis, gastric acid hypersecretion can occur, leading to exacerbation of pancreatic inflammation. Pantoprazole is a proton pump inhibitor that helps reduce gastric acid secretion, which can alleviate pancreatic irritation. IV administration ensures rapid onset of action.
B: Furosemide is a diuretic used for conditions like heart failure or edema, not indicated for acute pancreatitis.
C: Lactulose is a laxative used for hepatic encephalopathy to reduce ammonia levels, not indicated for acute pancreatitis.
D: Acetaminophen is a pain reliever, but it does not address the underlying cause of acute pancreatitis.
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A nurse is caring for a client who is receiving cisplatin to treat bladder cancer. After several treatments, the client reports fatigue. Which of the following actions should the nurse take?
- A. Check the results of the client's most recent CBC
- B. Administer a blood transfusion
- C. Offer the client a stimulant medication
- D. Advise the client to reduce physical activity
Correct Answer: A
Rationale: The correct answer is A: Check the results of the client's most recent CBC. Fatigue is a common side effect of cisplatin, which can cause bone marrow suppression leading to anemia. Checking the CBC will help determine if the client is experiencing anemia, which can be managed with appropriate interventions. Administering a blood transfusion (B) should not be done without confirming the need through lab results. Offering a stimulant medication (C) may mask the underlying cause of fatigue. Advising the client to reduce physical activity (D) may not address the root cause of the fatigue.
A nurse is reviewing the laboratory data of a client who has acute pancreatitis. The nurse should expect to find an elevation of which of the following values?
- A. Creatinine
- B. Bilirubin
- C. Amylase
- D. Albumin
Correct Answer: C
Rationale: The correct answer is C: Amylase. In acute pancreatitis, there is inflammation of the pancreas leading to leakage of pancreatic enzymes like amylase into the blood. Elevated amylase levels are a hallmark of acute pancreatitis. Creatinine (A) is related to kidney function, bilirubin (B) to liver function, and albumin (D) to protein status. In acute pancreatitis, the focus is on pancreatic enzymes like amylase.
A nurse is teaching a class about preventive care to clients who are at risk for acquiring viral hepatitis. Which of the following information should the nurse include in the presentation?
- A. Avoid foods prepared with tap water.
- B. Vaccination against hepatitis B and C is recommended.
- C. Wash hands thoroughly after using the restroom.
- D. Food should be prepared with purified water.
Correct Answer: D
Rationale: The correct answer is D: Food should be prepared with purified water. Hepatitis A virus can be spread through contaminated water or food. Using purified water for food preparation can help prevent the transmission of the virus. Choice A is incorrect because avoiding foods prepared with tap water alone may not be sufficient to prevent hepatitis. Choice B is incorrect as there is no vaccination available for hepatitis C. Choice C is important for general hygiene but may not specifically prevent hepatitis transmission.
A staff nurse is teaching a client who has Addison's disease about the disease process. The client asks the nurse what causes Addison's disease. Which of the following responses should the nurse make?
- A. It is caused by the lack of production of aldosterone by the adrenal gland.
- B. It is caused by a viral infection.
- C. It is caused by the overproduction of cortisol.
- D. It is caused by an autoimmune disorder.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Addison's disease is characterized by adrenal insufficiency.
2. Aldosterone is a hormone produced by the adrenal gland that helps regulate blood pressure and electrolyte balance.
3. Lack of aldosterone production in Addison's disease leads to electrolyte imbalances and low blood pressure.
4. Therefore, the correct answer is A as the lack of aldosterone production by the adrenal gland is the primary cause of Addison's disease.
Summary of other choices:
B. Addison's disease is not caused by a viral infection, so this choice is incorrect.
C. Addison's disease is not caused by the overproduction of cortisol, as it is associated with cortisol deficiency.
D. The most common cause of Addison's disease is an autoimmune disorder where the body attacks the adrenal glands, leading to their dysfunction.
A nurse is assessing a client who is 1 day postoperative following a lobectomy and has a chest tube drainage system in place. Which of the following findings by the nurse indicates a need for intervention?
- A. Clear breath sounds on the affected side
- B. Reduction in drainage output
- C. Development of subcutaneous emphysema
- D. Minimal pain at the surgical site
Correct Answer: C
Rationale: Subcutaneous emphysema, where air gets trapped under the skin, may indicate an underlying pneumothorax and should be reported to the provider.