Nokea
An adult has been stung by a bee and is in anaphylactic shock. An epinephrine (adrenaline) injection has been given. The nurse would expect which the following if the injection has been effective?
- A. The client's breathing will become easier
- B. The client's blood pressure will decrease
- C. There will be an increase in angiodema
- D. There will be a decrease in the client's level of consciousness
Correct Answer: A
Rationale: An epinephrine (adrenaline) injection is the first-line treatment for anaphylaxis, as it helps to relax the muscles in the airway and improve breathing. This results in the client's breathing becoming easier. Epinephrine also acts to increase blood pressure, while angioedema (swelling) and a decreased level of consciousness are not expected effects of an effective epinephrine injection.
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A 70-year old male diagnosed with BPH (benign prostatic hyperplasia) asks the nurse about his disease. The best response would be:
- A. "It an be caused by chronic infection of the urinary tract."
- B. "It was caused by your chronic cigarette smoking."
- C. "As you age, hormonal imbalances are the more likey cause of your disease."
- D. "Chronic obstruction of the bladder due to stone can cause BPH."
Correct Answer: C
Rationale: Option C, "As you age, hormonal imbalances are the more likely cause of your disease," is the best response. Benign prostatic hyperplasia (BPH) is a common condition in aging men characterized by an enlarged prostate gland. It is predominantly influenced by hormonal changes, specifically the imbalance between levels of testosterone and estrogen as men age. This hormonal imbalance leads to the proliferation of prostatic tissue and subsequent enlargement of the prostate gland, causing symptoms such as urinary frequency, urgency, weak stream, and difficulty emptying the bladder. Chronic infection of the urinary tract (Option A) and chronic cigarette smoking (Option B) are not the primary causes of BPH. While chronic obstruction of the bladder due to a stone (Option D) can cause similar symptoms to BPH, the underlying etiology of BPH is related to hormonal changes associated with aging.
The LEAST important advice for a 2-month-old baby with excessive crying is
- A. master the situation in relaxed manner
- B. adhere to precry cues
- C. change milk formula
- D. avoid sensory overstimulation
Correct Answer: C
Rationale: Changing formula may not address refusal due to developmental factors.
A client receiving ferrous sulfate (Fer-Iron) therapy to treat an iron deficiency reports taking an antacid frequently to relieve heart burn. Which nursing instruction should the nurse provide?
- A. "Take ferrous sulfate and the antacid together."
- B. "Take ferrous sulfate and the antacid at least 2 hours apart."
- C. "Avoid taking an antacid altogether."
- D. "Take ferrous sulfate and the antacid at least 1 hour apart."
Correct Answer: B
Rationale: Antacids can interfere with the absorption of iron from ferrous sulfate. Therefore, it is important to take these medications at least 2 hours apart to ensure proper absorption of the iron supplement. Taking them together can reduce the effectiveness of the ferrous sulfate therapy in treating the iron deficiency. It is not necessary to avoid taking an antacid altogether, but timing is crucial to optimize the benefits of both medications.
A client is being treated for acute pyelonephritis and will undergo laboratory tests. These tests are expected to help determine the clients BUN, creatinine, and serum electrolyte levels. Why should the nurse evaluate these test results?
- A. To determine the severity of the disorder
- B. To identify signs of fluid retention
- C. To determine the location of discomfort
- D. To determine clients response to therapy
Correct Answer: A
Rationale: Evaluating the client's BUN, creatinine, and serum electrolyte levels when being treated for acute pyelonephritis is crucial in determining the severity of the disorder. BUN and creatinine levels are indicators of renal function, where elevated levels may suggest impaired kidney function due to inflammation in the kidneys from pyelonephritis. Abnormal electrolyte levels, such as potassium and sodium, may also reflect the impact of the infection on renal function. Therefore, monitoring these test results helps healthcare providers assess how well the kidneys are functioning and the severity of the pyelonephritis to guide appropriate treatment decisions.
To supplement a diet with foods high in potassium, the nurse should recommend the addition of:
- A. Fruits such as bananas
- B. Milk and yogurt
- C. Green leafy vegetables
- D. Nuts and legumes
Correct Answer: A
Rationale: Fruits such as bananas are a good source of potassium. Potassium is an essential mineral that plays a vital role in various bodily functions, including maintaining proper muscle function, nerve transmission, and fluid balance. Bananas are easy to incorporate into the diet and provide a significant amount of potassium per serving. Other fruits high in potassium include oranges, melons, and avocados. Therefore, recommending the addition of fruits such as bananas is a suitable way to supplement a diet with foods high in potassium.