Nokea
The client who has undergone a bilateral adrenalectomy is ready to return home. She tells the nurse that she is concerned about persistent body changes and the fact that her moods are still so unpredictable. She says, 'I thought surgery was supposed to fix all that.' The nurse should tell the client that:
- A. The body changes are permanent and the client will not be the same as before this condition.'
- B. The body and mood will gradually return to normal.'
- C. The physical changes are permanent, but the mood swings will disappear.'
- D. The physical changes are temporary, but the mood swings are permanent.'
Correct Answer: B
Rationale: Post-adrenalectomy, with proper hormone replacement, physical changes and mood swings gradually resolve as hormone levels normalize.
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Immediately after a lumbar laminectomy, the nurse administers ondansetron hydrochloride (Zofran) to the client as ordered. The nurse determines that the drug is effective when which of the following is controlled?
- A. Muscle spasms.
- B. Nausea.
- C. Shivering.
- D. Dry mouth.
Correct Answer: B
Rationale: Ondansetron is an antiemetic, effective when nausea is controlled.
The home health nurse is discussing the administration of insulin glargine with a client. It would require follow-up if the client states that insulin glargine must be administered
- A. only in the abdomen.
- B. using a 6 mm and 31-gauge insulin syringe.
- C. only with a meal.
- D. after rolling the vial of insulin.
- E. within 28 days of opening the vial.
Correct Answer: A,C,D
Rationale: Insulin glargine can be administered in multiple sites, not only the abdomen; it is given regardless of meals; and it should not be rolled, as it is a clear solution.
A male client who has been taking warfarin (Coumadin) has been admitted with severe acute rectal bleeding and the following laboratory results: International Normalized Ratio (INR), 8; hemoglobin, 11 g/dL; and hematocrit, 33%. Which of the following physician orders should the nurse expect to implement initially? Select all that apply.
- A. Administer I.V. dextrose 5% in 0.45% normal saline solution.
- B. Schedule client for a sigmoidoscopy in the morning.
- C. Give 1 unit fresh frozen plasma (FFP).
- D. Administer vitamin K (AquaMEPHYTON) 2.5 mg.
- E. Begin giving polyethylene glycol-electrolyte solution (GoLYTELY) in preparation for sigmoidoscopy.
- F. Administer Fleet enema.
Correct Answer: C,D
Rationale: An INR of 8 indicates excessive anticoagulation from warfarin, causing severe bleeding. Initial management includes administering fresh frozen plasma (FFP) to replace clotting factors and vitamin K to reverse warfarin's effects. Dextrose/saline, sigmoidoscopy preparation, and enemas are not immediate priorities.
After a total laryngectomy, the client has a feeding tube. The feeding tube is effective if the tube feedings:
- A. Meet the fluid and nutritional needs of the client.
- B. Prevent aspiration.
- C. Prevent fistula formation.
- D. Maintain an open airway.
Correct Answer: A
Rationale: The primary purpose of a feeding tube post-laryngectomy is to meet the client's fluid and nutritional needs, as oral intake may be impaired due to surgical changes.
A nurse is providing education in a community setting about general measures to avoid excessive sun exposure. Which of the following recommendations is appropriate?
- A. Apply sunscreen only after going into the water.
- B. Avoid peak exposure hours from 9 a.m. to 1 p.m.
- C. Wear loosely woven clothing for added ventilation.
- D. Apply sunscreen with a sun protection factor (SPF) of 15 or more before sun exposure.
Correct Answer: D
Rationale: Applying sunscreen with SPF 15 or higher before sun exposure is a key measure to prevent UV damage. Sunscreen should be applied before water exposure, peak hours are 10 a.m. to 4 p.m., and tightly woven clothing is better for protection.