Nokea
As the nurse begins to administer scheduled doses of furosemide and nifedipine, the client asks for a PRN dose of aluminum hydroxide. Which action by the nurse would be best ensure the effectiveness of all the medications?
- A. Assess the client's immediate need for the antacid.
- B. Administer all three medications at the same time.
- C. Administer the nifedipine and aluminum hydroxide, then the furosemide 1 hour later.
- D. Administer the furosemide and aluminum hydroxide, then the nifedipine 1 hour later.
Correct Answer: A
Rationale: Antacids such as aluminum hydroxide often interfere with the absorption of other medications. For this reason, antacids should be separated from other medications by at least 1 hour. Because of the diuretic action of the furosemide and the antihypertensive action of the nifedipine, it is important to administer them on time if the client can tolerate waiting for the aluminum hydroxide. The nurse should assess the client to determine the need for the antacid.
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The nurse has a prescription to ambulate a client with a nephrostomy tube four times a day. The nurse determines that the safest way to ambulate the client while maintaining the integrity of the nephrostomy tube is to implement which intervention?
- A. Change the drainage bag to a leg collection bag.
- B. Tie the drainage bag to the client's waist while ambulating.
- C. Use a walker to hang the drainage bag from while ambulating.
- D. Tell the client to hold the drainage bag higher than the level of the bladder.
Correct Answer: A
Rationale: The safest approach to protect the integrity and safety of the nephrostomy tube with a mobile client is to attach the tube to a leg collection bag. This allows for greater freedom of movement, while preventing accidental disconnection or dislodgment. The drainage bag is kept below the level of the bladder. Option 3 presents the risk of tension or pulling on the nephrostomy tube by the client during ambulation.
The nurse is caring for a client with a terminal condition who is dying. Which respiratory assessment findings should indicate to the nurse that death is imminent? Select all that apply.
- A. Dyspnea
- B. Cyanosis
- C. Tachypnea
- D. Kussmaul's respiration
- E. Irregular respiratory pattern
- F. Adventitious bubbling lung sounds
Correct Answer: A,B,E,F
Rationale: Respiratory assessment findings that indicate death is imminent include poor gas exchange as evidenced by hypoxia, dyspnea, or cyanosis; altered patterns of respiration, such as slow, labored, irregular, or Cheyne-Stokes pattern (alternating periods of apnea and deep, rapid breathing); increased respiratory secretions and adventitious bubbling lung sounds (death rattle); and irritation of the tracheobronchial airway as evidenced by hiccups, chest pain, fatigue, or exhaustion. Kussmaul's respirations are abnormally deep, very rapid sighing respirations characteristic of diabetic ketoacidosis. Tachypnea is defined as rapid breathing.
A client is intubated and receiving mechanical ventilation. The primary health care provider has added 7 cm of positive end-expiratory pressure (PEEP) to the client's ventilator settings. The nurse should assess for which expected but adverse effect of PEEP?
- A. Decreased peak pressure on the ventilator
- B. Increased rectal temperature from 98°F to 100°F
- C. Decreased heart rate from 78 to 64 beats per minute
- D. Systolic blood pressure decrease from 122 to 98 mm Hg
Correct Answer: D
Rationale: PEEP improves oxygenation by enhancing gas exchange and preventing atelectasis. PEEP leads to increased intrathoracic pressure, which in turn leads to decreased cardiac output. This is manifested in the client by decreased systolic blood pressure and increased pulse (compensatory). Peak pressures on the ventilator should not be affected, although the pressure at the end of expiration remains positive at the level set for the PEEP. Fever indicates respiratory infection or infection from another source.
The nurse is assessing a client diagnosed with cardiac disease at the 30 weeks' gestation antenatal visit. The nurse assesses lung sounds in the lower lobes after a routine blood pressure screening. The nurse performs this assessment to elicit what information?
- A. Identify mitral valve prolapse.
- B. Identify cardiac dysrhythmias.
- C. Rule out the possibility of pneumonia.
- D. Assess for early signs of heart failure (HF).
Correct Answer: D
Rationale: Fluid volume during pregnancy peaks between 18 and 32 weeks' gestation. During this period, it is essential to observe and record maternal data that would indicate further signs of cardiac decompensation or HF in the pregnant client with cardiac disease. By assessing lung sounds, the nurse may identify early symptoms of diminished oxygen exchange and potential HF. Options 1, 2, and 3 are not related to the data in the question.
The nurse provides discharge instructions to a client who is recovering from testicular cancer surgery. Which instruction should the nurse include?
- A. To avoid driving a car for at least 2 weeks
- B. Not to be fitted for a prosthesis for at least 3 months
- C. To avoid sitting for long periods for at least 2 weeks
- D. To report any elevation in temperature to the primary health care provider
Correct Answer: D
Rationale: For the client who has had testicular surgery, the nurse should emphasize the importance of notifying the primary health care provider if chills, fever, drainage, redness, or discharge occurs. These symptoms may indicate the presence of an infection. One week after testicular surgery, the client may drive. Often, a prosthesis is inserted during surgery. Sitting needs to be avoided with prostate surgery because of the risk of hemorrhage, but this risk is not as high with testicular surgery.