Nokea
The client's serum potassium level is elevated in acute renal failure, and the nurse administers sodium polystyrene sulfonate (Kayexalate). This drug acts to:
- A. Increase potassium excretion from the colon.
- B. Release hydrogen ions for sodium ions.
- C. Increase calcium absorption in the colon.
- D. Exchange sodium for potassium ions in the colon.
Correct Answer: D
Rationale: Kayexalate exchanges sodium for potassium in the colon, reducing serum potassium levels in acute renal failure.
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A client is being switched from levodopa (L-dopa) to carbidopa-levodopa (Sinemet). The nurse should monitor for which of the following possible complications during medication changes and dosage adjustment?
- A. Euphoria.
- B. Jaundice.
- C. A military fluctuation.
- D. Signs and symptoms of diabetes.
Correct Answer: B
Rationale: Jaundice may indicate hepatotoxicity, a rare but serious complication of levodopa or carbidopa-levodopa. Euphoria, motor fluctuations, and diabetes are not primary concerns during this switch.
A client with a diagnosis of cancer is frequently disruptive and challenges the nurse. This behavior is probably caused by:
- A. Uncertainty and an underlying fear of recurrence.
- B. The usual trajectory of a short-term illness.
- C. A history of a behavioral illness.
- D. The one-time crisis from learning of the diagnosis.
Correct Answer: A
Rationale: Disruptive behavior in a cancer client is often driven by uncertainty and fear of recurrence, reflecting ongoing emotional distress.
The nurse has placed the intubated client with acute respiratory distress syndrome (ARDS) in prone position for 30 minutes. Which of the following would require the nurse to discontinue prone positioning and return the client to the supine position? Select all that apply.
- A. The family is coming in to visit.
- B. The client has increased secretions requiring frequent suctioning.
- C. The SpO2 and PO2 have decreased.
- D. The client is tachycardic with drop in blood pressure.
- E. The face has increased skin breakdown and edema.
Correct Answer: C,D,E
Rationale: Decreased SpO2/PO2 (C), tachycardia with hypotension (D), and facial skin breakdown/edema (E) indicate complications requiring a return to supine position. Family visits and suctioning needs are manageable in prone position.
The nurse is planning care for a client who had surgery for abdominal aortic aneurysm repair 2 days ago. The pain medication and the use of relaxation and imagery techniques are not relieving the client's pain and the client refuses to get out of bed to ambulate as ordered. The nurse contacts the physician, explains the situation, and provides information about drug dose, frequency of administration, the client's vital signs, and the client's score on the pain scale. The physician tells the nurse that the current order for pain medication is sufficient and the client will be fine in a few days. The nurse should next:
- A. Explain to the physician that the current pain medication and other strategies are not helping the client and it is making it difficult for the client to ambulate as ordered
- B. Ask the hospitalist to write an order for a stronger pain medication
- C. Wait until the next shift and ask the nurse on that shift to contact the physician
- D. Report the incident to the team leader
Correct Answer: A
Rationale: The nurse should advocate for the client by reiterating to the physician that the current pain management is ineffective, preventing ambulation, which is critical for recovery post-AAA repair. This aligns with ethical and professional standards. Asking another provider, waiting, or reporting to the team leader delays care.
A client was admitted to the hospital with iron deficiency anemia and blood-streaked emesis. Which question is most appropriate for the nurse to ask in determining the extent of the client's activity intolerance?
- A. What daily activities were you able to do 6 months ago compared with the present?'
- B. How long have you had this problem?'
- C. Have you been able to keep up with all your usual activities?'
- D. Are you more tired now than you used to be?'
Correct Answer: A
Rationale: To assess activity intolerance, the nurse should compare the client's current activity level with their previous capabilities. Asking about specific activities performed 6 months ago versus now provides concrete data on the extent of intolerance. The other questions are less specific and do not directly quantify changes in activity capacity.