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: A low urine output of 20mL/hour shortly after kidney transplant surgery is a critical finding that must be reported to the physician immediately. Adequate urine output is essential to ensure proper kidney function and the body's ability to eliminate waste products and regulate electrolyte levels. A urine output of less than 30mL/hour is considered oliguria, which may indicate decreased kidney function or potential complications such as acute kidney injury. Therefore, prompt evaluation and intervention are necessary to prevent further kidney damage or complications in the client.
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The nurse is assisting the family of a child with a history of encopresis. Which should be included in the nurse's discussion with this family?
- A. Instruct the parents to sit the child on the toilet at twice-daily routine intervals.
- B. Instruct the parents that the child will probably need to have daily enemas.
- C. Suggest the use of stimulant cathartics weekly.
- D. Reassure the family that most problems are resolved successfully, with some relapses during periods of stress.
Correct Answer: D
Rationale: The most appropriate response for the nurse to include in the discussion with the family of a child with a history of encopresis is to reassure them that most problems are resolved successfully, with some relapses during periods of stress. Encopresis is a common disorder in childhood, characterized by the repeated passage of feces in inappropriate places. It is often related to chronic constipation and fecal impaction. Treatment for encopresis includes addressing the underlying constipation through interventions like dietary changes, behavioral therapies, and possibly medications. It is important for the nurse to educate the family that although it may take time and effort, most children improve with treatment. Reassuring the family that relapses during periods of stress are to be expected can help to alleviate some of their anxiety and encourage them to continue with the treatment plan.
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: Acetylcysteine (Mucomyst) is the antidote for acetaminophen (Tylenol) overdose. If an overdose of acetaminincophen is suspected, acetylcysteine should be administered within 8-10 hours of ingestion to prevent liver damage and failure. Pentostatin, Fludarabine, and Auranofin are not antidotes for acetaminophen overdose and are used for other medical conditions.
The health-care provider diagnosed a child with Legg-Calve-Perthes disease. The parents expressed their concern to you that their child's leg will be amputated. How should you respond?
- A. It is too soon to determine if amputation is necessary.
- B. No amputation is necessary because the child will make a full recovery once the disease runs its course.
- C. The health-care provider is the best person to talk to you about amputation.
- D. Not all children who have the disease require amputation.
Correct Answer: D
Rationale: Legg-Calve-Perthes disease, also known as Perthes disease, is a condition where there is a temporary loss of blood supply to the hip, leading to the breakdown of the hip joint. While in severe cases amputation may be considered as a treatment option, it is important to reassure the parents that not all children with Legg-Calve-Perthes disease require amputation. The course of treatment will depend on the severity of the condition and the individual child's response to different therapies. Therefore, it is crucial to emphasize that amputation is not the automatic outcome for all cases of Legg-Calve-Perthes disease. Encouraging the parents to discuss their concerns with the healthcare provider can provide more specific information and guidance tailored to their child's condition.
Alaric was diagnosed with minimal-change nephrotic syndrome; which of the following signs and symptoms are characteristics of the said disorder?
- A. Hypertension, edema, hematuria
- B. Hypertension, edema, proteinuria
- C. Gross hematuria, fever, proteinuria
- D. Poor appetite, edema, proteinuria
Correct Answer: B
Rationale: Minimal-change nephrotic syndrome is a kidney disorder characterized by the presence of proteinuria, which is the excessive loss of protein in the urine. This leads to low levels of protein in the blood, causing edema (swelling) due to fluid accumulation in the tissues. In minimal-change nephrotic syndrome, hypertension (high blood pressure) is not a typical finding. Instead, patients often present with normal blood pressure levels. Additionally, hematuria (presence of blood in the urine) is not a common symptom of this disorder. Therefore, the key signs and symptoms characteristic of minimal-change nephrotic syndrome are edema, proteinuria, and the absence of hypertension.
When instructing the client diagnosed with hyperparathyroidism about diet, the nurse should stress the importance of which of the following?
- A. Restricting fluids
- B. Forcing fluids
- C. Restricting sodium
- D. Restricting potassium
Correct Answer: C
Rationale: For clients diagnosed with hyperparathyroidism, it is important to restrict sodium in the diet. High sodium intake can worsen calcium loss from the bones and increase the risk of kidney stones, both of which are concerns for individuals with hyperparathyroidism. Therefore, it is crucial to advise the client to limit their sodium intake to help manage their condition effectively.