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The nurse admits a patient to the unit and learns the patient has recently been diagnosed with chronic renal failure but has not informed the primary care provider of this diagnosis. What is the nurse's first priority?
- A. Maintain the patient's confidentiality.
- B. Administer medications ordered immediately.
- C. Provide teaching about chronic renal failure.
- D. Call the admitting physician immediately.
Correct Answer: D
Rationale: The correct answer is D: Call the admitting physician immediately. The nurse's first priority should be to inform the physician of the patient's recent diagnosis of chronic renal failure to ensure appropriate care and treatment. This action is crucial for the patient's safety and well-being. Maintaining confidentiality (A) is important but not the priority in this situation. Administering medications (B) should only be done after informing the physician about the diagnosis. Providing teaching (C) about the condition can wait until the physician is informed.
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A nurse is instructing a pregnant patient concerning the potential risk to her fetus from a pregnancy category B drug. What would the nurse inform the patient?
- A. There is evidence of human fetal risk, but the potential benefits from the use of the drug may be acceptable despite potential risks.
- B. Animal studies have shown an adverse effect on the fetus, but there are no adequate studies in pregnant women.
- C. Adequate studies in pregnant women have demonstrated that there is no risk to the fetus.
- D. Animal studies have not demonstrated a risk to the fetus, but there have been no adequate studies in pregnant women.
Correct Answer: D
Rationale: The correct answer is D. The nurse would inform the patient that animal studies have not demonstrated a risk to the fetus, but there have been no adequate studies in pregnant women. This is because Pregnancy Category B drugs have shown no adverse effects in animal studies, but there is a lack of human data. Choice A is incorrect as it implies evidence of fetal risk in humans. Choice B is incorrect because it states adverse effects in animal studies without human data. Choice C is incorrect as it claims no risk based on limited studies. Therefore, the correct answer is D as it accurately reflects the classification of Pregnancy Category B drugs.
A nurse is caring for a newly admitted patient who will receive Digoxin to treat cardiac dysrhythmia. The patient takes hydrochlorothiazide and reports regular use of OTC laxatives. Before administering the first dose of Digoxin, the nurse will review the patient's electrolyte levels with careful attention to which electrolytes?
- A. Calcium and magnesium.
- B. Potassium and chloride.
- C. Potassium and magnesium.
- D. Sodium and calcium.
Correct Answer: C
Rationale: The correct answer is C: Potassium and magnesium. Digoxin can cause toxicity in patients with low potassium or low magnesium levels, which can be exacerbated by the use of hydrochlorothiazide and OTC laxatives. Monitoring potassium and magnesium levels is crucial to prevent adverse effects such as cardiac dysrhythmias. Calcium and magnesium (choice A) are important electrolytes, but potassium is more critical in the context of Digoxin therapy. Potassium and chloride (choice B) are both important electrolytes, but magnesium should also be monitored. Sodium and calcium (choice D) are not the most relevant electrolytes to monitor in this situation.
A 54-year-old man has a myocardial infarction, resulting in left-sided heart failure. The nurse caring for the man is most concerned that he will develop edema in what area of the body.
- A. Peripheral.
- B. Pulmonary.
- C. Liver.
- D. Abdominal.
Correct Answer: B
Rationale: The correct answer is B: Pulmonary. Left-sided heart failure leads to the accumulation of fluid in the lungs, causing pulmonary edema. As the heart fails to pump effectively, blood backs up into the pulmonary circulation, leading to increased pressure in the blood vessels of the lungs. This results in fluid leakage into the alveoli, impairing gas exchange and causing symptoms like shortness of breath and coughing. Peripheral edema (choice A) occurs in right-sided heart failure due to fluid accumulation in the extremities. Liver congestion (choice C) can lead to hepatomegaly but is not the primary concern in this case. Abdominal edema (choice D) may occur in severe cases but is not as immediate a concern as pulmonary edema in left-sided heart failure.
A nurse is caring for a six-year-old child who had surgery that morning. The child is awake and lying very still in bed. What should the nurse do?
- A. Use an “ouch†scale for pain assessment.
- B. Encourage the child to request pain medication when needed.
- C. Plan to administer pain medication if the child begins to cry.
- D. Ask the child to rate their pain on a scale of 1 to 10.
Correct Answer: A
Rationale: The correct answer is A: Use an "ouch" scale for pain assessment. This approach is appropriate for a six-year-old child as it uses a simple and understandable method to assess pain levels. The child may not verbalize pain or cry, so using a visual scale like an "ouch" scale can help the nurse accurately assess the child's pain level. Encouraging the child to request pain medication (B) assumes the child will always feel comfortable expressing their needs, which may not be the case. Planning to administer pain medication if the child cries (C) may lead to unnecessary medication administration if the child is not in pain. Asking the child to rate their pain on a scale of 1 to 10 (D) may be too complex for a young child to understand and communicate effectively.
Which patient may require a higher-than-expected dose of an opioid analgesic?
- A. A patient 3 days after surgery.
- B. A patient with cancer.
- C. A patient with hypotension.
- D. A patient with a concussion.
Correct Answer: B
Rationale: The correct answer is B: A patient with cancer. Patients with cancer often have higher pain levels due to tumor growth, nerve compression, or treatment side effects, requiring higher opioid doses for adequate pain relief. Patients 3 days after surgery (A) may need opioids initially but typically require lower doses as pain decreases. Patients with hypotension (C) may be more sensitive to opioids, necessitating lower doses. Patients with a concussion (D) may have altered mental status, making opioid use risky.