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Following a unilateral adrenalectomy, the nurse would assess for hyperkalemia shown by which of the following?
- A. Muscle weakness
- B. Diaphoresis
- C. Tremors
- D. Constipation
Correct Answer: A
Rationale: The correct answer is A: Muscle weakness. After unilateral adrenalectomy, there is a risk of hyperkalemia due to decreased aldosterone production. Aldosterone helps regulate potassium levels in the body. Muscle weakness is a common symptom of hyperkalemia as high potassium levels can affect muscle function. Diaphoresis, tremors, and constipation are not typically associated with hyperkalemia. Diaphoresis is excessive sweating, tremors are involuntary muscle movements, and constipation is difficulty passing stool. These symptoms are not directly related to potassium imbalance.
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The nurse has taught a patient with thrombocytopenia how to prevent bleeding. Which of the ff. is the best evidence that the teaching has been effective?
- A. The patient states that he will be careful to avoid injury.
- B. The patient can list signs and symptoms of bleeding.
- C. The patient uses an electric razor instead of his safety razor.
- D. The patient states when he should call the doctor.
Correct Answer: C
Rationale: The correct answer is C because using an electric razor instead of a safety razor demonstrates understanding of the risk of injury associated with thrombocytopenia. This action shows practical application of the teaching to prevent bleeding. Choice A only indicates awareness but not necessarily action. Choice B shows knowledge but not necessarily application. Choice D is related to general healthcare knowledge but not directly linked to bleeding prevention in thrombocytopenia.
The nurse practitioner assesses a client in the physician’s office. Which assessment findings support a suspicion of systemic lupus erythematosus (SLE)?
- A. Facial erythema, profuse proteinuria, pleuritis, fever, and weight loss
- B. Pericarditis, photosensitivity, polyarthralgia, and painful mucous membrane ulcers
- C. Weight gain, hypervigilance, hypothermia, and edema of the legs
- D. Hypothermia, weight gain, lethargy, and edema of the arms
Correct Answer: B
Rationale: The correct answer is B because the assessment findings of pericarditis, photosensitivity, polyarthralgia, and painful mucous membrane ulcers are classic manifestations of systemic lupus erythematosus (SLE). Pericarditis can present as chest pain aggravated by deep breathing or lying flat, photosensitivity refers to skin rashes triggered by sunlight exposure, polyarthralgia involves joint pain in multiple joints, and painful mucous membrane ulcers are common in the mouth or nose. These findings align with the diagnostic criteria for SLE.
Choices A, C, and D are incorrect because they do not align with the typical presentation of SLE. Choice A includes facial erythema which is a common symptom, but the presence of profuse proteinuria, pleuritis, fever, and weight loss are not specific to SLE. Choices C and D include symptoms like weight gain, hypothermia, and edema which are not characteristic of SLE.
In summary
The nurse is caring for a patient who requires a complex dressing change. While in the patient’s room, the nurse decides to change the dressing. Which action will the nurse take just before changing the dressing?
- A. Gathers and organizes needed supplies
- B. Decides on goals and outcomes for the patient
- C. Assesses the patient’s readiness for the procedure
- D. Calls for assistance from another nursing staff member
Correct Answer: A
Rationale: The correct answer is A because gathering and organizing needed supplies is a crucial step before performing a complex dressing change. By ensuring all necessary supplies are readily available, the nurse can streamline the process, minimize interruptions, and promote efficiency. This step also helps maintain aseptic technique and prevent the spread of infection. Deciding on goals and outcomes (B) is important but typically done as part of the care planning process, not immediately before a dressing change. Assessing the patient's readiness (C) is also important but can be done concurrently with gathering supplies. Calling for assistance (D) may be necessary in some situations, but it is not the immediate step required just before changing the dressing.
A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate?
- A. Infusing IV fluids rapidly as ordered
- B. Administering glucose-containing IV
- C. Encouraging increased oral intake fluids as ordered
- D. Restricting fluids
Correct Answer: D
Rationale: The correct answer is D: Restricting fluids. In SIADH, there is an excess of antidiuretic hormone leading to water retention and dilutional hyponatremia. Restricting fluids helps to prevent further water retention and hyponatremia. Rapid IV fluid infusion (A) worsens the condition by further diluting sodium levels. Administering glucose-containing IV (B) is not directly related to treating SIADH. Encouraging increased oral intake (C) can exacerbate the condition by increasing fluid intake.
A client receives a sealed radiation implant to treat cervical cancer. When caring for this client, the nurse should:
- A. Consider the client’s urine, feces, and vomitus to be highly radioactive
- B. Consider the client to be radioactive for 10 days after implant removal
- C. Allow soiled linens to remain in the room until after the client is discharged
- D. Maintain the client on complete bed rest with bathroom privileges only
Correct Answer: B
Rationale: The correct answer is B because the client remains radioactive for a period of time after the implant removal, typically around 10 days. During this time, the nurse should take precautions to limit exposure to radiation. Choice A is incorrect because bodily fluids are not highly radioactive, and proper disposal procedures should be followed. Choice C is incorrect as soiled linens should be handled appropriately to prevent contamination. Choice D is incorrect as bed rest may not be necessary, and mobility should be encouraged within safety guidelines.