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After medicating the client for pain and collecting granules and stones from strained urine, which action is most important for the nurse to implement next?
- A. Send the calculi for laboratory analysis of stone composition.
- B. Evaluate the client for persistent pain.
- C. Assess the clarity of urine.
- D. Encourage high fluid intake to produce urine output of 2L/day.
Correct Answer: A
Rationale: Sending the calculi for analysis is crucial in determining the type of stone present. Identifying the stone composition helps in developing an effective treatment plan and preventive measures to avoid future episodes of urolithiasis. This step is essential in providing targeted care for the client. Options B, C, and D are not the most important actions at this point. While evaluating for persistent pain is essential, determining the stone composition takes precedence to guide appropriate interventions.
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The nurse is assessing a client with Addison's disease who is weak, dizzy, disoriented, and has dry oral mucous membranes, poor skin turgor, and sunken eyes. Vital signs are blood pressure 94/44, heart rate 123 beats/minute, respiration 22 breaths/minute. Which intervention should the nurse implement first?
- A. Assess extremity strength and resistance
- B. Report a sodium level of 132 mEq/L or mmol/L (SI units)
- C. Measure and record the cardiac QRS complex
- D. Check current finger stick glucose
Correct Answer: D
Rationale: The client's symptoms suggest possible adrenal crisis or hypoglycemia. Checking glucose is a priority to rule out hypoglycemia, which requires immediate intervention. The client is presenting with symptoms indicative of hypoglycemia, which can be life-threatening if not promptly addressed. Assessing extremity strength, reporting sodium levels, or measuring the cardiac QRS complex are not the most urgent actions in this scenario.
The healthcare provider prescribes potassium chloride 25 mEq in 500 ml D5W to infuse over 6 hours. The available 20 ml vial of potassium chloride is labeled '10 mEq/5 ml.' How many ml of potassium chloride should the nurse add to the IV fluid?
- A. 12.5
- B. 5
- C. 10
- D. 20
Correct Answer: B
Rationale: To prepare 25 mEq of potassium chloride for the infusion, the nurse should add 5 ml of the 10 mEq/5 ml solution. This concentration provides the required amount of potassium chloride without exceeding the needed volume. Choice A would result in 12.5 mEq, which exceeds the prescribed amount. Choices C and D are incorrect as they do not align with the correct calculation based on the vial concentration.
After undergoing an uncomplicated gastric bypass surgery, a client is experiencing difficulty managing their diet. What dietary instruction is most important for the nurse to explain to the client?
- A. Chew food slowly and thoroughly before attempting to swallow
- B. Plan volume-controlled evenly spaced meals throughout the day
- C. Sip fluid slowly with each meal and between meals
- D. Eliminate or reduce intake of fatty and gas-forming foods
Correct Answer: A
Rationale: The correct answer is A. Thoroughly chewing food is crucial for clients who have undergone gastric bypass surgery to aid in digestion and prevent complications. Proper chewing helps break down food into smaller particles, making it easier for the digestive system to process. This instruction is essential to prevent issues such as food blockages or inadequate nutrient absorption. Choices B and C are also important for post-gastric bypass clients to maintain proper nutrition and hydration, but they are not as critical as ensuring thorough chewing. Choice D addresses dietary concerns but is not as immediately crucial as ensuring the client chews food properly to support digestion and prevent complications.
Which action should the nurse include in the plan of care for a client receiving acyclovir (Zovirax) IV for treatment of herpes zoster (shingles)?
- A. Initiate cardiac telemetry monitoring
- B. Maintain continuous pulse oximetry
- C. Perform capillary glucose measurements
- D. Monitor serum creatinine levels
Correct Answer: D
Rationale: The correct answer is D: Monitor serum creatinine levels. Acyclovir can lead to nephrotoxicity, making it essential to monitor kidney function through serum creatinine levels. While cardiac telemetry monitoring (choice A) and maintaining continuous pulse oximetry (choice B) are important in certain conditions, they are not directly related to acyclovir therapy for herpes zoster. Performing capillary glucose measurements (choice C) is not a priority when administering acyclovir for herpes zoster. Monitoring serum creatinine levels is crucial to detect any potential renal issues early, as the drug's nephrotoxic potential requires close monitoring of kidney function.
A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely?
- A. Hypokalemia
- B. Ketonuria
- C. Peripheral edema
- D. Elevated blood pressure
Correct Answer: A
Rationale: The correct answer is A: Hypokalemia. In diabetes insipidus, there is excessive urination leading to fluid loss, which can result in electrolyte imbalances such as hypokalemia. Monitoring potassium levels is crucial to prevent complications like cardiac arrhythmias. Choices B, C, and D are incorrect. Ketonuria is typically seen in diabetic ketoacidosis, peripheral edema is more commonly associated with conditions like heart failure or kidney disease, and elevated blood pressure is not a direct complication of diabetes insipidus related to a pituitary gland tumor.