A nurse is caring for a client who is in shock and is receiving an infusion of albumin. Which of the following findings should the nurse expect?
- A. Oxygen saturation 96%
- B. PaCO2 30 mm Hg
- C. Increase in BP
- D. Decrease in protein
Correct Answer: C
Rationale: The correct answer is C: Increase in BP. Albumin is a colloid solution that helps increase blood volume and subsequently improves blood pressure in shock patients. Increasing blood volume leads to an increase in blood pressure. Option A is incorrect because oxygen saturation is not directly affected by albumin infusion. Option B is incorrect because a low PaCO2 level is not a direct effect of albumin infusion. Option D is incorrect because albumin is a protein and its infusion would not lead to a decrease in protein levels.
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A nurse is consulting a formulary about a client's new prescription for raloxifene. The nurse should identify that this medication is used to treat which of the following conditions?
- A. Osteoporosis
- B. Hypothyroidism
- C. Urinary tract infection
Correct Answer: A
Rationale: The correct answer is A: Osteoporosis. Raloxifene is a medication used to prevent and treat osteoporosis by increasing bone density. It is a selective estrogen receptor modulator that mimics estrogen's effects on bone without affecting other tissues like the uterus. This helps to reduce the risk of fractures in postmenopausal women. Choices B, C, D, E, F, and G are incorrect because raloxifene is not indicated for hypothyroidism, urinary tract infections, or any other conditions besides osteoporosis.
A nurse is caring for a client receiving gentamicin. Which of the following should the nurse monitor the client for?
- A. Prostephobia
- B. Tireibus
- C. Polyuria
- D. Tathyramda
Correct Answer: C
Rationale: The correct answer is C: Polyuria. Gentamicin is an antibiotic known to potentially cause kidney damage, leading to impaired kidney function and decreased urine output. Therefore, monitoring for polyuria (excessive urine output) is crucial to assess the client's renal function. Prostephobia, Tireibus, and Tathyramda are not known side effects or complications associated with gentamicin use. Prostephobia is not a medical term, and Tireibus and Tathyramda are not relevant to gentamicin therapy. The nurse should focus on monitoring the client for signs of kidney damage, such as changes in urine output, in this scenario.
A nurse is teaching a client about oral contraceptive. Which of the following information should the nurse include in the teaching?
- A. Abdominal pain is an expected adverse effect of oral contraceptives
- B. It can take up to 1 year to become pregnant after stopping an oral contraceptive
- C. Some herbal supplements can decrease the effectiveness of an oral contraceptive
- D. A pelvic examination is needed prior to starting an oral contraceptive
Correct Answer: C
Rationale: The correct answer is C: Some herbal supplements can decrease the effectiveness of an oral contraceptive. The nurse should include this information in the teaching to ensure the client understands potential interactions. Herbal supplements like St. John's Wort can reduce the effectiveness of oral contraceptives by increasing their metabolism. This can lead to contraceptive failure and unintended pregnancy. Option A is incorrect because abdominal pain is not an expected adverse effect of oral contraceptives. Option B is incorrect as fertility typically returns quickly after stopping oral contraceptives, not taking up to a year. Option D is incorrect as a pelvic examination is not always necessary before starting oral contraceptives.
The nurse is ready to begin the blood transfusion. For each potential nursing action, click to specify if the action is indicated or not indicated for the client.
- A. Document the blood product transfusion in the client's medical record.
- B. Stay with the client for the first 15 min of the transfusion.
- C. Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg.
- D. Obtain the first unit of packed RBCs from the blood bank.
- E. Start an IV bolus of lactated Ringer's solution.
Correct Answer: B
Rationale: [0, 1, 0, 0]
The correct answer is Stay with the client for the first 15 min of the transfusion. This action is indicated to monitor for adverse reactions such as fever, chills, or signs of hemolysis. Documenting the blood product transfusion (A) is important but not a priority during the initial phase. Titrating the infusion rate (C) and obtaining the blood product (D) are essential, but staying with the client for monitoring takes precedence. Starting an IV bolus (E) is not related to blood transfusion monitoring.
A nurse is assessing a client following the administration of ondansetron (Zofran). Which of the following findings should indicate to the nurse that the ondansetron has been effective?
- A. Client reports a decrease in pain
- B. Client reports a decrease in nausea
- C. Client reports a decrease in coughing
- D. Client reports a decrease in diarrhea
Correct Answer: B
Rationale: The correct answer is B: Client reports a decrease in nausea. Ondansetron is primarily used to treat nausea and vomiting. If the client reports a decrease in nausea, it indicates that the medication has been effective in managing this specific symptom. Decrease in pain (choice A) is not directly related to the action of ondansetron. Choices C (decrease in coughing) and D (decrease in diarrhea) are not typical indications of ondansetron's effectiveness. It is important for the nurse to focus on the specific expected outcome of the medication, which is the reduction of nausea and vomiting.