Nokea
Mr. Go had a post-kidney transplant. What should the nurse immediately assess?
- A. fluid and electrolyte imbalances
- B. hepatotoxicity
- C. infection
- D. respiratory complications
Correct Answer: A
Rationale: After a kidney transplant, it is essential for the nurse to immediately assess for fluid and electrolyte imbalances in the recipient. The transplanted kidney may take some time to start functioning optimally, and during this period, the body may not be able to regulate fluid and electrolyte balance effectively. Monitoring for signs of fluid overload, electrolyte disturbances, and kidney function is crucial to prevent complications such as dehydration, electrolyte abnormalities, and organ rejection. Early detection of these imbalances allows for prompt intervention and prevention of potential complications.
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A patient has allergic rhinitis. In planning care for the patient, the nurse understands that if the patient does not remain compliant with the treatment regimen, the patient is at risk for developing which of the following?
- A. Sinusitis
- B. Lymphadenopathy
- C. Anaphylaxis
- D. Angioedema
Correct Answer: A
Rationale: Allergic rhinitis is characterized by inflammation of the nasal passages due to exposure to allergens. If a patient with allergic rhinitis does not remain compliant with the treatment regimen, such as taking antihistamines or using nasal corticosteroids, it can lead to chronic inflammation and congestion of the nasal passages. Over time, this chronic inflammation can predispose the patient to developing complications such as sinusitis, which is the inflammation of the sinuses. Sinusitis can result in symptoms such as facial pain, pressure, nasal congestion, and fever. Therefore, non-compliance with treatment in allergic rhinitis can increase the risk of developing sinusitis as a complication.
The nurse is using calipers to measure skinfold thickness over the triceps muscle in a school- age child. What is the purpose of doing this?
- A. To measure body fat
- B. To measure muscle mass
- C. To determine arm circumference
- D. To determine accuracy of weight measurement
Correct Answer: A
Rationale: Skinfold thickness measurements using calipers are commonly used in assessing body composition, specifically to estimate body fat percentage. By measuring skinfold thickness over the triceps muscle in combination with measurements from other sites on the body, healthcare professionals can estimate the amount of subcutaneous fat present. This information is valuable in evaluating an individual's overall body composition and health status. The triceps skinfold measurement is a commonly included site in body fat calculations, especially in school-age children, where it can provide insights into growth and development.
When instructing the client diagnosed with hyperparathyroidism about diet, the nurse should stress the importance of which of the following?
- A. Restricting fluids
- B. Forcing fluids
- C. Restricting sodium
- D. Restricting potassium
Correct Answer: C
Rationale: For clients diagnosed with hyperparathyroidism, it is important to restrict sodium in the diet. High sodium intake can worsen calcium loss from the bones and increase the risk of kidney stones, both of which are concerns for individuals with hyperparathyroidism. Therefore, it is crucial to advise the client to limit their sodium intake to help manage their condition effectively.
On the third day after a partial thyroidectomy, a client exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and fingertips. Suspecting a life- threatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery?
- A. Hypocalcemia
- B. Hyperkalemia
- C. Hyponatremia
- D. Hypermagnesemia
Correct Answer: A
Rationale: Hypocalcemia is the most common electrolyte disturbance that follows thyroid surgery, particularly after a partial thyroidectomy. This occurs due to inadvertent injury or removal of the parathyroid glands, which are responsible for regulating calcium levels in the body. The symptoms of hypocalcemia, such as muscle twitching, hyperirritability of the nervous system, numbness, and tingling, align with the client's presentation in this scenario. Prompt recognition and treatment of hypocalcemia are crucial to prevent life-threatening complications like tetany or seizures. Therefore, the nurse's decision to notify the surgeon immediately is appropriate to address this electrolyte imbalance.
What is the role of a nurse during scratch test to detect allergies?
- A. Applying the liquid test antigen
- B. Determining the type of allergy
- C. Measuring the length and width of the
- D. Documenting the findings raised wheal
Correct Answer: A
Rationale: During a scratch test to detect allergies, one of the key roles of a nurse is to apply the liquid test antigen onto the patient's skin. The liquid test antigen contains small amounts of common allergens that could trigger a reaction in individuals who are allergic to them. By applying the test antigen onto the skin and creating small scratches or pricks, the nurse can observe if the patient develops a raised, red, itchy bump called a wheal at the site of the allergen exposure. This helps in identifying specific allergies and determining the appropriate treatment plan for the patient.