Nokea
A nurse is educating a client and his family about vasopressin (DDAVP) for the treatment of diabetes insipidus. In addition to administration instructions, which of the following should the nurse discuss with the client and family? Select all that apply.
- A. Wearing a medical alert bracelet
- B. Monitoring the daily intake of fluids
- C. Avoiding sun exposure while using the drug
- D. Carrying extra doses with the client at all times
- E. Carrying liquids with the client at all times
Correct Answer: A,B,D,E
Rationale: In addition to administration instructions, the nurse should include the following: wear a medical alert bracelet, monitor the daily intake and output of fluids, avoid the use of alcohol, and carry extra doses and liquids with the client at all times.
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A client is receiving treatment with adrenocorticotropic hormone. The nurse would instruct the client to avoid receiving which vaccine? Select all that apply.
- A. Zostavax (shingles)
- B. Meruvax (rubella)
- C. Td (tetanus and diphtheria)
- D. Fluzone (influenza)
- E. Attenuvax (measles)
Correct Answer: A,B,E
Rationale: Clients taking ACTH should avoid any vaccination with live virus including Zostavax, Meruvax, and Attenuvax.
A client is receiving corticosteroid therapy. Which nursing diagnosis would the nurse be least likely to identify for this client?
- A. Risk for Infection
- B. Disturbed Body Image
- C. Risk for Injury
- D. Deficient Fluid Volume
Correct Answer: D
Rationale: A client who is receiving corticosteroid therapy would be least likely to have a nursing diagnosis of Deficient Fluid Volume. Rather, Excess Fluid Volume would be more appropriate. Risk for Infection related to immunosuppression, Disturbed Body Image related to cushingoid effects, and Risk for Injury related to muscle atrophy and osteoporosis would be appropriate.
A nurse would administer vasopressin (Pressyn) cautiously to a client with which of the following? Select all that apply.
- A. Sleep apnea
- B. Migraine headaches
- C. Asthma
- D. Seizure disorders
- E. Angina
Correct Answer: B,C,D,E
Rationale: Vasopressin (Pressyn) is used cautiously in clients with a history of seizure disorder, migraine headaches, asthma, congestive heart failure, or vascular disease (angina and myocardial infarction).
Which of the following should be included in the nurse's preadministration assessment of a client receiving desmopressin (DDAVP) for relief of abdominal distention? Select all that apply.
- A. Abdominal girth
- B. Weight
- C. Pulse
- D. Respiratory rate
- E. Blood glucose
Correct Answer: A,C,D
Rationale: Blood pressure, pulse, respiratory rate, and abdominal girth should be included in the nurse's preadministration assessment of a client receiving desmopressin (DDAVP) for relief of abdominal distention.
A client receiving gonadotropin therapy comes to the clinic for follow-up. Which of the following would the nurse immediately report to the primary health care provider? Select all that apply.
- A. Ascites
- B. Abdominal distention
- C. Abdominal pain
- D. Weight gain
- E. Irritability
Correct Answer: A,B,C
Rationale: The client is at risk for ovarian enlargement manifested by abdominal distention, pain, and ascites (with serious cases). The nurse would immediately notify the primary health care provider and the drug would be discontinued at the first sign of ovarian stimulation or enlargement. Weight gain and irritability would not need to be reported immediately.