Nokea
The client is in end-stage renal disease and is receiving sodium polystyrene sulfonate (Kayexalate) via an enema. Which data indicate the medication is effective?
- A. The client has 30 mL/hr of urine output.
- B. The serum phosphorus level has decreased.
- C. The client is in normal sinus rhythm.
- D. The client's serum potassium level is 5 mEq/L.
Correct Answer: D
Rationale: Kayexalate lowers serum potassium in hyperkalemia; a level of 5 mEq/L (normal) indicates effectiveness. Urine, phosphorus, or rhythm are unrelated.
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The nurse is applying silver sulfadiazine (Silvadene) to a child with severe burns to arms and legs. Which side effect should the nurse be monitoring for?
- A. Skin discoloration
- B. Hardened eschar
- C. Increased neutrophils
- D. Urine sulfa crystals
Correct Answer: D
Rationale: Urine sulfa crystals. When applied to extensive areas, silver sulfadiazine may cause a transient neutropenia, as well as renal function changes with sulfa crystals production and kernicterus.
A woman with a 28 week pregnancy is on the way to the emergency department by ambulance with a tentative diagnosis of abruptio placenta. Which should the nurse do first when the woman arrives?
- A. administer oxygen by mask at 100%
- B. start a second IV with an 18 gauge cannula
- C. check fetal heart rate every 15 minutes
- D. insert urethral catheter with hourly urine outputs
Correct Answer: A
Rationale: administer oxygen by mask at 100%. Administering oxygen in this situation would increase the circulating oxygen in the mother's circulation to the fetus's circulation. This action will minimize complications.
The client diagnosed with angina must receive a two (2)-inch nitroglycerin paste (Nitro-Bid) application. Which interventions should the nurse implement? Select all that apply.
- A. Wear gloves when administering.
- B. Remove the old Nitro-Bid paper.
- C. Apply the paper on a hairy spot.
- D. Put medication only on the legs.
- E. Report any headache to the HCP.
Correct Answer: A,B
Rationale: Gloves prevent nurse absorption, and removing old paste ensures accurate dosing. Hairy spots reduce adhesion, leg-only application is incorrect, and headaches are expected.
The client admitted with pneumonia is taking Imuran, an immunosuppressive agent. Which question should the nurse ask the client regarding this medication?
- A. Do you know this medication has to be tapered off when discontinued?
- B. Have you been exposed to viral hepatitis B or C recently?
- C. Why are you taking this medication, and how long have you taken it?
- D. Do you have a lot of allergies or sensitivities to different medications?
Correct Answer: C
Rationale: Imuran (azathioprine) use and duration clarify indication (e.g., autoimmune) and infection risk, critical with pneumonia. Tapering, hepatitis, or allergies are less immediate.
A client who has Hodgkin's disease receives a weekly IV dose of nitrogen mustard. Which nursing order is most appropriate for this client?
- A. Encourage mouth care with an astringent mouthwash and dental floss after every meal
- B. Encourage organ meats and dried beans and peas
- C. Monitor vital signs daily
- D. Encourage fluid intake to 3000 cc
Correct Answer: D
Rationale: Nitrogen mustard causes bone marrow suppression and nausea; high fluid intake helps flush the drug and prevent dehydration.