Nokea
The client with CRF receives a sodium polystyrene sulfonate enema. Which finding indicates that the medication is achieving the desired therapeutic effect?
- A. Returns of dark-colored stool
- B. Able to retain solution for 1 hour
- C. Verbalizes relief of constipation
- D. Serum potassium level 4.0 mEq/L
Correct Answer: D
Rationale: A: Although sodium polystyrene sulfonate may be administered as an enema and stool may return, the purpose of the medication is to lower serum potassium levels and not to empty the bowel. B: The client should be encouraged to retain the enema solution for as long as possible so that sodium ions can be exchanged for potassium ions in the intestine, but its retention for this length of time does not indicate its effectiveness in lowering the serum potassium level. C: The client may be constipated prior to receiving the enema, but this is not the purpose of a sodium polystyrene sulfonate enema. D: Sodium polystyrene sulfonate exchanges sodium ions for potassium ions in the intestine and is administered when the client has hyperkalemia. A normal serum potassium level of 4.0 mEq/L indicates that the medication is achieving its desired therapeutic effect.
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The nurse completes teaching insulin administration to the parent of the toddler newly diagnosed with type 1 DM. The nurse concludes that the teaching was successful when the parent makes which statement?
- A. NPH insulin is only given at night immediately before the bedtime snack.
- B. I should use only the buttocks for the insulin injections until the child is older.
- C. Insulin lispro acts within 15 minutes and peaks 30 to 90 minutes after injection.
- D. Insulin detemir can be added to the insulin lispro pen to reduce the number of injections.
Correct Answer: C
Rationale: A: NPH (Humulin N) insulin can be given in the morning, but there is better glucose control if given at night. NPH peaks in 4 to 14 hours, so there is no need to make sure food is given immediately after administration. B: Insulin injections should always be rotated to prevent subcutaneous tissue damage from giving the injections in the same location. C: Lispro (Humalog) is rapid-acting insulin that peaks in 30 to 90 minutes and may last as long as 5 hours in the blood. This statement is correct, indicating teaching is effective. D: Detemir (Levemir) is long-acting and lispro (Humalog) is rapid-acting insulin. An insulin pen uses prefilled, multiple-use insulin cartridges; adding other types of insulins should not be attempted.
What is pica?
- A. dependency on alcohol
- B. increased iron in the diet
- C. the sickle cell trait
- D. eating ice
Correct Answer: D
Rationale: Pica represents the ingestion of nonfood substances that leads to a clinical iron deficiency and might actually be the first sign of a problem. Clients eat a wide range of nonfood items, including ice, clay, dirt, and paste.
The client with Addison's disease is taking fludrocortisone 100 mcg orally once daily. Which statement made by the client regarding the fludrocortisone therapy requires further teaching by the nurse?
- A. I should talk to my health care provider about getting a flu shot this year.
- B. I should stop taking fludrocortisone if my blood sugar levels are too high.
- C. I should check my weight, blood pressure, and pulse once every morning.
- D. I should eat foods higher in potassium like bananas, melons, and pears.
Correct Answer: B
Rationale: A: The client should check with the HCP about getting vaccinations such as influenza; a chronic condition increases the client's risk for other illnesses and complications. B: The client needs further teaching if stating that he or she will stop taking fludrocortisone (Florinef) if his or her blood sugar levels are too high; stopping mineralocorticoid replacement therapy abruptly may lead to addisonian crisis. C: Common adverse effects of fludrocortisone include edema, arrhythmias, and hypertension; stating that he or she should monitor weight, BP, and pulse daily is appropriate. D: Common adverse effects of fludrocortisone include hypokalemia; stating that he or she should consume potassium-rich foods is appropriate.
When administering intravenous electrolyte solution, the nurse should take which of the following precautions?
- A. Infuse hypertonic solutions rapidly.
- B. Mix no more than 80 mEq of potassium per liter of fluid.
- C. Prevent infiltration of calcium, which causes tissue necrosis and sloughing.
- D. As appropriate, reevaluate the client's digitalis dosage. He might need an increased dosage because IV calcium diminishes digitalis's action.
Correct Answer: C
Rationale: Preventing tissue infiltration is important to avoid tissue necrosis. Choice A is incorrect because hypertonic solutions should be infused cautiously and checked with the RN if there is a concern. Choice B is incorrect because potassium, mixed in the pharmacy per physician order, is mixed at a concentration no higher than 60 mEq/L.
What is the threshold of dextrose concentrations that can safely be administered through a peripheral IV?
- A. Dextrose concentrations below 20% can be safely administered through a peripheral IV; dextrose concentrations above 20% should not be administered through a peripheral IV.
- B. Dextrose concentrations below 5% can safely be administered through a peripheral IV; dextrose concentrations above 5% should not be administered through a peripheral IV.
- C. Dextrose concentrations below 10% can safely be administered through a peripheral IV; dextrose concentrations above 10% should not be administered through a peripheral IV.
- D. Dextrose concentrations above 5% can safely be administered through a peripheral IV; dextrose concentrations below 5% should not be administered through a peripheral IV.
Correct Answer: C
Rationale: Administering dextrose concentrations above 10% through a peripheral IV can lead to phlebitis. It is safe to administer dextrose concentrations below 10% through a peripheral IV.