Nokea
The nurse assesses a client shortly after kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?
- A. Serum potassium level of 4.9mEq/L
- B. Temperature of 99.2F (37.3C)
- C. Serum sodium level of 135mEq/L
- D. Urine output of 20mL/hour
Correct Answer: D
Rationale: The correct answer is D: Urine output of 20mL/hour. This is a critical finding after kidney transplant surgery as it indicates potential kidney dysfunction or acute kidney injury. Decreased urine output can lead to fluid and electrolyte imbalances, which can be life-threatening. Immediate physician notification is crucial for prompt intervention. Choices A, B, and C are within normal ranges and do not indicate immediate danger. Serum potassium level of 4.9mEq/L is slightly elevated but not critical. Temperature of 99.2F (37.3C) is within normal limits for postoperative care. Serum sodium level of 135mEq/L is also normal and does not warrant immediate physician notification.
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A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first?
- A. Complete the questions in chronological order.
- B. Focus on the patient’s presenting situation.
- C. Make accurate interpretations of the data.
- D. Conduct an observational overview.
Correct Answer: B
Rationale: The correct answer is B: Focus on the patient’s presenting situation. In the problem-oriented approach, the nurse prioritizes the patient's immediate concerns to address them effectively. By focusing on the presenting situation first, the nurse can gather relevant data and identify key issues. This step ensures that the nurse addresses the most pressing problems promptly.
A: Completing questions in chronological order may not be necessary and could delay addressing the immediate concern.
C: Making accurate interpretations of data should come after gathering relevant information about the presenting situation.
D: Conducting an observational overview is important but should come after focusing on the patient's presenting situation to gather specific data.
A client becomes upset when the physician diagnoses diabetes mellitus as the cause of current signs and symptoms. The client tells the nurse, “This must be a mistake. No one in my family has ever had diabetes.” Based on this statement, the nurse suspects the client is using which coping mechanism?
- A. Denial
- B. Anger
- C. Withdrawal
- D. Resolution
Correct Answer: A
Rationale: The correct answer is A: Denial. The client's refusal to accept the diagnosis of diabetes mellitus, stating that no one in their family has had it, indicates denial as a coping mechanism. Denial is a defense mechanism where individuals refuse to acknowledge unpleasant realities. In this case, the client is rejecting the diagnosis to avoid facing the reality of having a chronic condition. The other choices (B: Anger, C: Withdrawal, D: Resolution) do not fit the client's response in this scenario. Anger involves expressing frustration or hostility, withdrawal is avoiding the situation, and resolution is accepting and dealing with the issue.
A patient asks the nurse what her diagnosis of heart failure means. Which of the ff. is the nurse’s best response?
- A. “Your heart briefly stops.”
- B. “Your heart has an area of muscle that is dead.”
- C. “Your heart is pumping to much blood.”
- D. “Your heart is not an efficient pump.”
Correct Answer: D
Rationale: The correct answer is D: “Your heart is not an efficient pump.” This response is the best choice as it accurately describes heart failure, which is a condition where the heart is unable to pump blood effectively. This leads to symptoms such as fatigue, shortness of breath, and fluid retention.
Explanation:
1. Choice A is incorrect because heart failure does not mean the heart stops; it means the heart is not functioning properly.
2. Choice B is incorrect because heart failure does not necessarily mean there is dead muscle tissue in the heart.
3. Choice C is incorrect because heart failure is not about pumping too much blood; it is about the heart's inability to pump blood efficiently, leading to circulation problems and other symptoms.
The nurse is caring for a client who is receiving antibiotics to treat a gram-negative bacterial infection. Because antibiotics destroy the body’s normal flora, the nurse must monitor the client for:
- A. Platelet dysfunction
- B. Stomatitis
- C. Oliguria and dysuria
- D. Diarrhea
Correct Answer: D
Rationale: The correct answer is D: Diarrhea. Antibiotics can disrupt the normal balance of gut bacteria, leading to diarrhea. This occurs due to the overgrowth of harmful bacteria in the intestines. Monitoring for diarrhea is crucial to prevent dehydration and further complications. Platelet dysfunction (A), stomatitis (B), and oliguria/dysuria (C) are not typically associated with the disruption of normal flora by antibiotics. These symptoms are more likely related to other conditions or side effects of medications, making them incorrect choices in this scenario.
The nurse is caring for a client in the emergency room diagnosed with Bell’s palsy. The client has been taking acetaminophen (Tylenol), and acetaminophen overdose is suspected. The nurse anticipates that the antidote to be prescribed is:
- A. Pentostatin (Nipent)
- B. Fludarabine (Fludara)
- C. Auranofin (Ridaura)
- D. Acetylcysteine Mucomyst)
Correct Answer: D
Rationale: Rationale: Acetylcysteine (Mucomyst) is the antidote for acetaminophen overdose. It works by replenishing glutathione, which helps neutralize the toxic metabolite of acetaminophen. Pentostatin, Fludarabine, and Auranofin are not antidotes for acetaminophen overdose and are used for different conditions. Acetylcysteine is the correct choice as it directly counteracts the toxic effects of acetaminophen.