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Sulfadiazine has been ordered for a client who has a urinary tract infection. Which of the following recommend is most appropriate for administering sulfonamides?
- A. Encourage the client to take the medication with meals.
- B. Instruct the client to drink at least 8 glasses of water a day.
- C. Measure the client's urine output.
- D. Instruct the client that the urine may turn reddish orange.
Correct Answer: B
Rationale: Adequate hydration (8 glasses of water daily) prevents crystalluria, a complication of sulfonamides.
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A client is prescribed diphenhydramine 1% as a topical agent for allergic dermatosis. The nurse evaluates that the medication is having the intended effect when the client reports relief of what complaint?
- A. Pain
- B. Urticaria
- C. Headache
- D. Skin redness
Correct Answer: B
Rationale: Diphenhydramine is an antihistamine medication that has many uses. When used as a topical agent on the skin, it reduces the symptoms of allergic reaction, such as itching or urticaria. It does not act to relieve pain, headache, or skin redness.
A client who had undergone an abdominal hysterectomy is in the recovery room. The surgeon has ordered a 250-mL bolus of normal saline over 1 hour to replace blood loss. The I.V. solution infusing in the client was 1,000 mL normal saline with 40 mEq of potassium chloride at 100 mL/hour. The nurse should: Select all that apply.
- A. Increase the I.V. infusion rate to 250 mL/hour for 1 hour.
- B. Add 250 mL of normal saline to the current infusion bag and continue at 100 mL/hour.
- C. Connect a 250-mL bag of normal saline to the Y-connection and calculate to infuse over 1 hour.
- D. Contact the physician regarding continuation of the primary I.V. infusion during the bolus infusion.
- E. Administer the normal saline bolus via an I.V. infusion pump.
Correct Answer: C,E
Rationale: A separate 250-mL bag via Y-connection and infusion pump ensures accurate delivery of the bolus without altering the primary infusion.
Which of the following assessment finding is expected in a client with bacterial pneumonia?
- A. Increased fremitus.
- B. Bilateral expiratory wheezing.
- C. Resonance on percussion.
- D. Vesicular breath sounds.
Correct Answer: A
Rationale: Increased fremitus is expected in bacterial pneumonia due to lung consolidation.
A client with a history of hypothyroidism is admitted with fatigue. The nurse should monitor the client for which of the following laboratory abnormalities?
- A. Elevated thyroid-stimulating hormone (TSH).
- B. Decreased free T4.
- C. Elevated T3.
- D. Decreased TSH.
Correct Answer: A, B
Rationale: Hypothyroidism presents with elevated TSH and decreased free T4.
The nurse walks into the room of a client who has a 'do not resuscitate' order and finds the client without a pulse, respirations, or blood pressure. What is the most appropriate action?
- A. Stay in the room and notify the nursing team for assistance.
- B. Push the emergency alarm to call a code.
- C. Dial the hospital phone number for a code.
- D. Pull the curtain and leave the room.
Correct Answer: D
Rationale: For a DNR client, no resuscitation is performed. The nurse should respectfully leave the room after ensuring privacy, notifying the team as needed for post-mortem care.