Nokea
The client in end-stage renal disease is receiving aluminium hydroxide (Amphojel). Which assessment data indicate the medication is effective?
- A. The client denies complaints of indigestion.
- B. The client is not experiencing burning on urination.
- C. The client has had a normal, soft bowel movement.
- D. The client's phosphate level has decreased.
Correct Answer: D
Rationale: Amphojel binds phosphate in ESRD, lowering serum levels; decreased phosphate indicates effectiveness. Indigestion, urination, or bowel movements are unrelated.
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The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority?
- A. Blanch nail beds for color and refill
- B. Assess for post-operative arrhythmias
- C. Auscultate for pulmonary congestion
- D. Monitor equality of peripheral pulses
Correct Answer: B
Rationale: Assess for post-operative arrhythmias. The atrioventricular bundle (bundle of His), a part of the electrical conduction system of the heart, extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening.
The nurse is assessing a client who is on long term glucocorticoid therapy. Which of the following findings would the nurse expect?
- A. Buffalo hump
- B. Increased muscle mass
- C. Peripheral edema
- D. Jaundice
Correct Answer: A
Rationale: Buffalo hump. With high doses of glucocorticoid, iatrogenic Cushing's syndrome develops. The exaggerated physiological action causes abnormal fat distribution which results in a moon-shaped face, an intrascapular pad on the neck (buffalo hump) and truncal obesity with slender limbs.
A 5 year-old has been rushed to the emergency room several hours after acetaminophen poisoning. Which laboratory result should receive attention by the nurse?
- A. Sedimentation rate
- B. Profile 2
- C. Bilirubin
- D. Neutrophils
Correct Answer: C
Rationale: Bilirubin. Bilirubin, along with liver enzymes ALT and AST, may rise in the second stage (1-3 days) after a significant overdose, indicating cellular necrosis and liver dysfunction.
Ringer's lactate is running at 125 mL/hr. The administration set has 15 drops/mL. What should the drip rate be?
- A. 8 drops/min
- B. 31 drops/min
- C. 50 drops/min
- D. 67 drops/min
Correct Answer: B
Rationale: Divide 125 mL/hr by 60 min/hr and multiply by 15 drops/mL: (125 ÷ 60) × 15 = 31.25, rounded to 31 drops/min.
A 19-year-old woman has just started taking birth control pills. She calls the clinic nurse to say that her breasts are tender and she is nauseous. The nurse's response is based on which understanding?
- A. These are serious side effects.
- B. These effects usually decrease after three to six cycles.
- C. Taking the pill in the morning reduces its side effects.
- D. Taking the pills every other day reduces its side effects.
Correct Answer: B
Rationale: Breast tenderness and nausea are common initial side effects of oral contraceptives, typically resolving after a few cycles.