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A nurse is assessing a 1-year-old child. Which of the following disorders should the nurse suspect? Which disorder should the nurse suspect in a 1-year-old?
- A. Intussusception.
- B. Wilms tumor.
- C. Pyloric stenosis.
- D. Nephritic syndrome.
Correct Answer: B
Rationale: The correct answer is B: Wilms tumor. This is because Wilms tumor is a common childhood kidney cancer that typically presents in children aged 1-5 years. The nurse should suspect Wilms tumor in a 1-year-old child due to the age range of presentation. Intussusception (A) is more common in infants aged 3-12 months. Pyloric stenosis (C) typically presents in infants around 2-8 weeks old. Nephritic syndrome (D) is more common in older children. Therefore, based on the age group and common presentation, Wilms tumor is the most likely disorder to suspect in a 1-year-old child.
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A nurse is caring for a patient who has a new prescription for atorvastatin. Which of the following instructions should the nurse include? What instructions should the nurse include for atorvastatin?
- A. Take the medication in the morning.
- B. Report muscle pain or weakness.
- C. Avoid foods high in vitamin K.
- D. Take the medication with grapefruit juice.
Correct Answer: B
Rationale: The correct answer is B: Report muscle pain or weakness. This is crucial because atorvastatin, a statin medication, can cause muscle-related side effects like myopathy or rhabdomyolysis. By instructing the patient to report muscle pain or weakness, the nurse can monitor for these serious adverse effects and take appropriate actions if needed.
A: Taking the medication in the morning is not specific to atorvastatin and can be taken at any time.
C: Avoiding foods high in vitamin K is not relevant to atorvastatin, as it does not interact with vitamin K.
D: Taking the medication with grapefruit juice is not recommended with atorvastatin as grapefruit juice can interact with certain medications, but not specifically with atorvastatin.
Nurse's Notes & Physical Examination
• The client arrived in the emergency department with complaints of fatigue, blurred vision, dizziness, and headache for the past two days. They report running out of blood glucose strips and insulin due to financial constraints. The client appears tired, is cooperative, and has a slightly dry mucous membrane. They are oriented to person, place, and time but seem concerned about their health status. The skin is warm and dry to the touch, with no visible rashes or lesions. Heart sounds are regular without murmurs; breath sounds are clear bilaterally. The abdomen is soft with no tenderness upon palpation. The client expresses anxiety about potential falls due to dizziness.
Vital Signs
• Blood Pressure: 120/72 mm Hg
• Temperature: 36.8° C (98.2° F)
• Pulse: 88/min
• Respirations: 20/min
Diagnostic Results
• Blood Glucose: 235 mg/dL (Reference range: 74-106 mg/dL)
• HbA1c: 8.4% (Target for diabetics: <7%)
• Hemoglobin: 14.2 g/dL (12-18 g/dL)
• Hematocrit: 42.6% (37-52%)
• WBC Count: 6000/mm³ (5000-10,000/mm³)
Provider's Prescriptions
• Increase glargine from 20 units to 25 units at bedtime.
• Continue other home medications as prescribed.
Scenario: A nurse is caring for a client admitted to the medical-surgical unit. The exhibits below detail the client's condition at different time points throughout the day. Review the exhibits and determine how the patient's condition evolves and whether it worsens or improves. The initial data is recorded at 0700 hrs, followed by subsequent observations at different times.
Based on the initial assessment and diagnostic results, what is the priority nursing intervention?
- A. Administer a bolus of IV fluids.
- B. Administer insulin.
- C. Administer oxygen therapy at 2 L/min via nasal cannula.
- D. Place the client on fall precautions and provide a bedside commode.
Correct Answer: A
Rationale: The correct answer is A: Administer a bolus of IV fluids. The priority nursing intervention is to address any immediate physiological needs identified in the initial assessment and diagnostic results. Administering IV fluids can help stabilize the client's fluid and electrolyte balance, ensuring proper circulation and organ function. This intervention takes precedence over the other options as it directly addresses a critical aspect of the client's condition. Administering insulin (choice B) may be necessary for managing specific conditions but is not the immediate priority. Oxygen therapy (choice C) may be beneficial, but if the client is in need of fluid resuscitation, addressing hypovolemia takes precedence. Fall precautions and providing a bedside commode (choice D) are important for safety but do not address the physiological needs identified in the initial assessment.
A nurse is caring for a patient who has a new prescription for lisinopril. Which of the following laboratory values should the nurse monitor? Which lab value should the nurse monitor for lisinopril?
- A. Serum potassium
- B. Serum calcium
- C. Serum magnesium
- D. Serum chloride
Correct Answer: A
Rationale: The nurse should monitor serum potassium levels because lisinopril, an ACE inhibitor, can cause potassium retention leading to hyperkalemia. Hyperkalemia can result in serious cardiac complications. Monitoring potassium levels allows timely intervention if levels become elevated. Serum calcium, magnesium, and chloride are not typically affected by lisinopril, making choices B, C, and D incorrect. The correct answer, A, is crucial for patient safety and reflects the physiological impact of lisinopril on potassium levels.
A nurse is caring for a client who has nausea and a prescription for metoclopramide intravenously every 8 hours as needed. The client asks the nurse how metoclopramide will relieve her nausea. Which explanation should the nurse provide?How does metoclopramide relieve nausea?
- A. The medication relieves nausea by promoting gastric emptying.
- B. The medication works by relaxing gastric muscles.
- C. The medication works by decreasing gastric acid secretions.
- D. The medication enhances gastric emptying.
Correct Answer: A,D
Rationale: The correct answers are A and D. Metoclopramide relieves nausea by promoting gastric emptying, which helps move food through the stomach faster. This action reduces the feeling of fullness and discomfort, ultimately alleviating nausea. Additionally, enhancing gastric emptying helps prevent reflux, which can contribute to nausea. Choices B and C are incorrect because metoclopramide does not work by relaxing gastric muscles or decreasing gastric acid secretions. These mechanisms do not directly address the issue of delayed gastric emptying, which is the primary reason for nausea relief with metoclopramide.
A nurse is caring for a patient who has a new prescription for omeprazole. Which of the following instructions should the nurse include? What instructions should the nurse include for omeprazole?
- A. Take the medication with food.
- B. Take the medication on an empty stomach.
- C. Take the medication at bedtime.
- D. Avoid taking with antacids.
Correct Answer: B
Rationale: The correct answer is B: Take the medication on an empty stomach. Omeprazole is a proton pump inhibitor that works best when taken on an empty stomach, at least 30 minutes before a meal. This allows for optimal absorption and effectiveness in reducing stomach acid production. Taking it with food may decrease its absorption and effectiveness. Choice A is incorrect because taking omeprazole with food can interfere with its absorption. Choice C is incorrect as taking it at bedtime may not provide the best conditions for absorption. Choice D is incorrect because omeprazole can be taken with antacids if needed, but it's best to separate the doses by at least 2 hours.