Nokea
Appropriate nursing diagnoses for a client with hypothyroidism would include which of the following?
- A. Risk for injury (corneal abrasion) related to incomplete closure of the eyelid.
- B. Imbalanced nutrition: Less than body requirements related to hypermetabolism.
- C. A clinical evidence related to diarrhea.
- D. Activity intolerance related to fatigue associated with the disorder.
Correct Answer: D
Rationale: Hypothyroidism causes fatigue due to slowed metabolism, making activity intolerance a relevant nursing diagnosis. The other options are more associated with hyperthyroidism or unrelated conditions.
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A client has renal colic due to renal lithiasis. What is the nurse's first priority in managing care for this client?
- A. I need to know the client to ingest fluids.
- B. Encourage the client to drink at least 500 mL of water each hour.
- C. Request the central supply department to send supplies for straining urine.
- D. Administer an opioid analgesic as prescribed.
Correct Answer: D
Rationale: Severe pain from renal colic is the priority, requiring opioid analgesics for immediate relief to improve client comfort and cooperation.
The physician prescribes metoclopramide hydrochloride (Reglan) for the client with hiatal hernia. The nurse plans to instruct the client that this drug is used in hiatal hernia therapy to accomplish which of the following objectives?
- A. Increase tone of the esophageal sphincter.
- B. Neutralize gastric secretions.
- C. Ease gastric emptying.
- D. Reduce secretion of digestive juices.
Correct Answer: C
Rationale: Metoclopramide promotes gastric emptying, reducing the volume of gastric contents that can reflux in hiatal hernia.
The surgeon orders cefazolin (Ancef) 1 g to be given I.V. at 7:30 a.m. when the client's surgery is scheduled at 8:00 a.m. What is the primary reason to start the antibiotic exactly at 7:30 a.m.?
- A. Legally the medication has to be given at the ordered time.
- B. The antibiotic is most effective in preventing infection if it is given 30 to 60 minutes before the operative incision is made.
- C. The postoperative dose of Ancef needs to be started exactly 8 hours after the preoperative dose of Ancef.
- D. The peak and titer levels are needed for antibiotic therapy.
Correct Answer: B
Rationale: Administering cefazolin 30 to 60 minutes before incision ensures optimal tissue levels to prevent surgical site infections. Timing is critical for prophylactic efficacy, not legal requirements or postoperative dosing schedules.
A client has a throbbing headache when nitroglycerin is taken for angina. The nurse should instruct the client that:
- A. Acetaminophen (Tylenol) or Ibuprofen (Advil) can be taken for this common side effect.
- B. Nitroglycerin should be avoided if the client is experiencing this serious side effect.
- C. Taking the nitroglycerin with a few glasses of water will reduce the problem.
- D. The client should lie in a supine position to alleviate the headache.
Correct Answer: A
Rationale: Headache is a common side effect of nitroglycerin due to vasodilation. Acetaminophen or ibuprofen can safely relieve it without discontinuing the medication.
The nurse is instructing a young adult with Addison's disease how to adjust the dose of glucocorticoids. The nurse should explain that the client may need an increased dosage of glucocorticoids in which of the following situations?
- A. Completing the spring semester of school.
- B. Gaining 4 pounds.
- C. Becoming engaged.
- D. Undergoing a root canal.
Correct Answer: D
Rationale: Stressful situations like surgery or dental procedures (e.g., root canal) increase glucocorticoid needs in Addison's disease to prevent adrenal crisis.