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Following a transsphenoidal hypophysectomy, the nurse should assess the client care fully for which of the following conditions?
- A. Hypocortisolism.
- B. Hyperglycemia
- C. Hypoglycemia
- D. Hypercalcemia
Correct Answer: A
Rationale: Following a transsphenoidal hypophysectomy, the nurse should assess the client carefully for hypocortisolism, also known as adrenal insufficiency. This is because the procedure involves removing the pituitary gland, which plays a critical role in regulating cortisol production by the adrenal glands. Without proper cortisol production, the client may develop symptoms such as weakness, fatigue, low blood pressure, weight loss, and nausea. Monitoring for signs of hypocortisolism is crucial for prompt detection and intervention to prevent adrenal crisis, which can be life-threatening. Hyperglycemia, hypoglycemia, and hypercalcemia are not typically direct concerns following a transsphenoidal hypophysectomy.
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The multilumen pulmonary artery catheter allows the nurse to measure hemodynamic pressures at different points in the heart. When the tip enters the small branches of the pulmonary artery, the nurse can assess all of the following except:
- A. Central venous pressure (CVP)
- B. Pulmonary artery capillary pressure (PACP)
- C. Pulmonary artery obstructive pressure (PACP)
- D. Pulmonary artery wedge pressure (PAWP)
Correct Answer: C
Rationale: The multilumen pulmonary artery catheter, when positioned in the small branches of the pulmonary artery, allows the nurse to measure various hemodynamic pressures. Central venous pressure (CVP), Pulmonary artery capillary pressure (PACP), and Pulmonary artery wedge pressure (PAWP) can be measured accurately at this point. However, "Pulmonary artery obstructive pressure" is not a valid or recognized hemodynamic pressure parameter. Instead, the correct term for this measurement that can be assessed using the catheter is the Pulmonary artery occlusion pressure (PAOP) or Pulmonary artery wedge pressure (PAWP), which reflects the left atrial pressure.
A clinical nurse specialist (CNS) is orienting a new graduate registered nurse to an oncology unit where blood product transfusions are frequently administered. In discussing ABO compatibility, the CNS presents several hypothetical scenarios. A well-informed new graduate would know the greatest likelihood of an acute hemolytic reaction would occur when giving:
- A. A-positive blood to an A-negative client
- B. O-positive blood to an A-positive client
- C. O-negative blood to an O-positive client
- D. B-positive blood to an AB-positive client
Correct Answer: B
Rationale: The greatest likelihood of an acute hemolytic reaction occurs when there is mismatch in the ABO blood group system, specifically when the recipient's plasma contains antibodies against the donor's red blood cells. In this scenario, giving O-positive blood to an A-positive client presents the highest risk because the A-positive client has anti-B antibodies in their plasma, which can attack the B antigens present on the O-positive donor red blood cells. This mismatch can lead to rapid destruction of the transfused red blood cells, causing an acute hemolytic reaction. It is crucial to ensure ABO compatibility to prevent such life-threatening reactions during blood product transfusions.
Then the drug is stopped. When should treatment resume?
- A. When the WBC falls to 5,000mm3
- B. When the WBC count rises to
- C. When lost hair begins to grow back 50,000/mm3
- D. When the client displays anemia
Correct Answer: A
Rationale: The drug should be resumed when the WBC (white blood cell) count falls to 5,000/mm3. This is the appropriate indicator to monitor as a low WBC count may indicate the need for the medication to be restarted to support the immune system. It is important to closely monitor the WBC count as it is a crucial factor in gauging the body's ability to fight infections effectively. Resuming treatment at this point helps ensure that the client's immune system remains stable and can continue to function properly.
What instruction should the nurse give to then patient taking propan0lol (Inderal) for hypertension?
- A. Have potassium level checked
- B. Do not stop medication abruptly
- C. Report any changes in appetite
- D. Resume usual daily activities
Correct Answer: B
Rationale: The nurse should instruct the patient taking propranolol (Inderal) for hypertension to not stop the medication abruptly. Suddenly stopping propranolol can lead to rebound hypertension and potentially dangerous side effects. It is important for the patient to gradually taper off the medication under the guidance of a healthcare provider to avoid complications. Therefore, advising the patient not to stop the medication abruptly is a crucial instruction to ensure their safety and well-being.
A 7-year-old child has been diagnosed with rheumatic fever. Which of the following physical findings would the nurse expect to assess?
- A. Vesicular rash over the face and chest
- B. Warm and swollen knees and elbows
- C. Palpable mass in the upper right quadrant of the abdomen
- D. Yellow pigmentation of the sclera of the eyes 103 the following meets the Jone's criteria?
Correct Answer: B
Rationale: Rheumatic fever is an inflammatory condition that can affect different parts of the body, including the joints. The typical physical finding in a child with rheumatic fever is warm and swollen joints, especially in the knees and elbows. This is known as migratory arthritis and is one of the major criteria in the Jones criteria for diagnosing rheumatic fever. Other major criteria include carditis, subcutaneous nodules, erythema marginatum, and Sydenham chorea. So, in a 7-year-old child diagnosed with rheumatic fever, the nurse would expect to assess warm and swollen joints as part of the physical examination.