Nokea
A nurse is conducting an assessment of a client who underwent thoracentesis of the right side of the chest 3 hours ago. Which findings does the nurse report to the physician? Select all that apply.
- A. Unequal chest expansion
- B. Pulse rate of 82 beats/min
- C. Respiratory rate of 22 breaths/min
- D. Diminished breath sounds in the right lung
Correct Answer: A
Rationale: After thoracentesis, the nurse should assess the client for signs of pneumothorax, which include increased respiratory rate, dyspnea, retractions, unequal chest expansion, diminished breath sounds, and cyanosis. Unequal chest expansion is a key sign of pneumothorax due to the accumulation of air in the pleural space, causing the affected lung to collapse partially. Pulse rate and respiratory rate within normal ranges, like in choices B and C, are not the priority findings to report in this situation. Diminished breath sounds in the right lung could be expected after thoracentesis and may not necessarily indicate a complication like pneumothorax, making choice D less urgent to report.
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The nurse is caring for a patient who has had severe vomiting. The patient's serum sodium level is 130 mEq/L. The nurse will expect the patient's provider to order which treatment?
- A. Diuretic therapy
- B. Intravenous hypertonic 5% saline
- C. Intravenous normal saline 0.9%
- D. Oral sodium supplements
Correct Answer: C
Rationale: In this scenario, the patient has hyponatremia with a serum sodium level of 130 mEq/L. For a serum sodium level between 125 and 135 mEq/L, the appropriate treatment is intravenous normal saline 0.9%. Normal saline helps to increase the sodium content in the vascular fluid. Diuretic therapy would exacerbate sodium and fluid depletion, which is not suitable for a patient already dehydrated from severe vomiting. Intravenous hypertonic 5% saline is typically reserved for severe hyponatremia with a serum sodium level below 120 mEq/L. Oral sodium supplements are not feasible in this case as the patient is vomiting and may not be able to tolerate oral intake easily.
A healthcare professional assesses clients on the medical-surgical unit. Which client is at greatest risk for the development of bacterial cystitis?
- A. A 36-year-old female who has never been pregnant
- B. A 42-year-old male who is prescribed cyclophosphamide
- C. A 58-year-old female who is not taking estrogen replacement
- D. A 77-year-old male with mild congestive heart failure
Correct Answer: C
Rationale: Females are at higher risk of developing bacterial cystitis due to their shorter urethra compared to males. Postmenopausal women not on estrogen replacement therapy are particularly susceptible to cystitis because of changes in vaginal and urethral cells. This increases the risk of bacterial infection. The other options do not have the same level of risk as the postmenopausal woman not using hormone replacement therapy. A never-pregnant middle-aged woman does not have the same increased risk as a postmenopausal woman with hormonal changes.
The patient is beginning furosemide and has started a 2-week course of a steroid medication. What should the nurse recommend?
- A. Avoid consuming licorice to prevent excess potassium loss.
- B. Report a urine output less than 600 mL/24 hours.
- C. Obtain an order for a potassium supplement.
- D. Take the furosemide in the morning.
Correct Answer: C
Rationale: When a patient is taking furosemide and a steroid medication, there is an increased risk of potassium loss due to the interaction between the two drugs. Consuming licorice should be avoided as it can worsen potassium loss. Reporting a urine output less than 600 mL/24 hours is not directly related to the drug interaction and may not be necessary. Taking furosemide at bedtime is not the primary concern when a patient is concurrently on a steroid medication and furosemide. Therefore, obtaining an order for a potassium supplement is the most appropriate recommendation to counteract the potential potassium loss.
The provider has ordered Kayexalate and sorbitol to be administered to a patient. The nurse caring for this patient would expect which serum electrolyte values prior to administration of this therapy?
- A. Sodium 125 mEq/L and potassium 2.5 mEq/L
- B. Sodium 150 mEq/L and potassium 3.6 mEq/L
- C. Sodium 135 mEq/L and potassium 6.9 mEq/L
- D. Sodium 148 mEq/L and potassium 5.5 mEq/L
Correct Answer: C
Rationale: Severe hyperkalemia, with a potassium level of 6.9 mEq/L, requires aggressive treatment with Kayexalate and sorbitol to increase the body's excretion of potassium. The normal range for serum potassium is 3.5 to 5.5 mEq/L, so patients with the other potassium levels would not be treated aggressively or would need potassium supplementation. Therefore, option C (Sodium 135 mEq/L and potassium 6.9 mEq/L) is the correct choice as it indicates severe hyperkalemia warranting the administration of Kayexalate and sorbitol. Options A, B, and D have either potassium levels within normal limits, which would not necessitate this aggressive treatment, or potassium levels that are lower than what would typically prompt the need for Kayexalate and sorbitol.
A client with a family history of polycystic kidney disease (PKD is being assessed by a nurse. For which clinical manifestations should the nurse assess? (Select all that apply.)
- A. Nocturia
- B. Flank pain
- C. Increased abdominal girth
- D. B & C
Correct Answer: D
Rationale: Clients with PKD commonly present with flank pain and increased abdominal girth due to abdominal distention caused by cysts. Bloody urine is also a common symptom due to tissue damage from PKD. Nocturia and dysuria are not typical manifestations of PKD. Constipation is not directly associated with PKD. Therefore, the correct choices are flank pain and increased abdominal girth, making option D the correct answer.