Nokea
The nurse formulates a nursing diagnosis of 'High risk for ineffective airway clearance' for a client with myasthenia gravis. What is the most likely etiology for this nursing diagnosis?
- A. Pain when coughing.
- B. Diminished cough effort.
- C. Thick, dry secretions.
- D. Excessive inflammation.
Correct Answer: B
Rationale: The correct answer is B: Diminished cough effort. In myasthenia gravis, muscle weakness can affect the respiratory muscles, leading to ineffective coughing and clearance of airways. Diminished cough effort can result in ineffective airway clearance, putting the client at high risk for respiratory complications.
A: Pain when coughing is not the primary etiology for ineffective airway clearance in myasthenia gravis.
C: Thick, dry secretions may contribute to airway clearance issues but are not the most likely etiology compared to diminished cough effort.
D: Excessive inflammation is not typically associated with ineffective airway clearance in myasthenia gravis.
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An elderly female client comes to the clinic for a regular check-up. The client tells the nurse that she has increased her daily doses of acetaminophen (Tylenol) for the past month to control joint pain. Based on this client's comment, what previous lab values should the nurse compare with today's lab report?
- A. Look at last quarter's hemoglobin and hematocrit to assess for dehydration.
- B. Look for an increase in today's LDH compared to the previous one to assess for possible liver damage.
- C. Expect to find an increase in today's APTT compared to last quarter's due to bleeding.
- D. Determine if there is a decrease in serum potassium due to renal compromise.
Correct Answer: B
Rationale: The correct answer is B. The nurse should look for an increase in today's LDH compared to the previous one to assess for possible liver damage. Acetaminophen overdose can lead to liver toxicity, which can be indicated by elevated LDH levels. LDH is an enzyme released during liver damage. Checking for LDH levels can help assess the impact of increased acetaminophen doses on the liver.
Choices A, C, and D are incorrect:
A: Looking at hemoglobin and hematocrit is not directly related to acetaminophen use for joint pain. It does not provide information about liver damage.
C: APTT measures blood clotting time and is not directly affected by acetaminophen use for joint pain. It does not provide information about liver damage.
D: Serum potassium levels are not typically affected by acetaminophen use for joint pain. It does not provide information about liver damage.
What is an important teaching point for a patient prescribed dabigatran for atrial fibrillation?
- A. Take the medication with food to enhance absorption.
- B. Do not crush or chew the capsules.
- C. Increase intake of green leafy vegetables.
- D. Avoid all dairy products.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Dabigatran is an anticoagulant medication that comes in capsules, which should not be crushed or chewed to maintain its extended-release formulation.
2. Crushing or chewing the capsules can lead to an increased risk of bleeding due to rapid release of the medication.
3. Therefore, advising the patient not to crush or chew the capsules is crucial to ensure the safety and efficacy of dabigatran therapy.
Summary:
A: Taking with food is not necessary for dabigatran absorption.
C: Green leafy vegetables are high in vitamin K, which can interfere with anticoagulant therapy.
D: There is no need to avoid all dairy products while taking dabigatran.
A patient with glaucoma is prescribed timolol eye drops. What is the primary action of this medication?
- A. Reduce intraocular pressure
- B. Dilate the pupils
- C. Constrict the pupils
- D. Enhance tear production
Correct Answer: A
Rationale: The correct answer is A: Reduce intraocular pressure. Timolol is a beta-blocker that works by decreasing the production of aqueous humor in the eye, thereby reducing intraocular pressure. This action helps to prevent damage to the optic nerve in patients with glaucoma. Choices B and C are incorrect because timolol does not affect pupil size. Choice D is incorrect because timolol does not enhance tear production; in fact, it may have a drying effect on the eyes.
A client is on a mechanical ventilator. Which client response indicates that the neuromuscular blocker tubocurarine chloride (Tubarine) is effective?
- A. The client's extremities are paralyzed.
- B. The peripheral nerve stimulator causes twitching.
- C. The client clenches fist upon command.
- D. The client's Glasgow Coma Scale score is 14.
Correct Answer: A
Rationale: The correct answer is A because the neuromuscular blocker tubocurarine chloride causes muscle paralysis, leading to the extremities being paralyzed. This indicates that the medication is effectively blocking neuromuscular transmission.
B: Twitching with peripheral nerve stimulation indicates incomplete blockade.
C: Clenching fist upon command indicates preserved muscle strength.
D: Glasgow Coma Scale measures level of consciousness, not neuromuscular blockade.
A client with heart failure is receiving intravenous furosemide (Lasix). Which assessment finding indicates that the medication is having the desired effect?
- A. Decreased peripheral edema.
- B. Elevated blood pressure.
- C. Increased heart rate.
- D. Decreased urine output.
Correct Answer: A
Rationale: The correct answer is A: Decreased peripheral edema. Furosemide is a diuretic that helps to remove excess fluid from the body, which can reduce peripheral edema in patients with heart failure. This indicates that the medication is effectively reducing fluid overload in the body. Elevated blood pressure (choice B) would not be an expected outcome of furosemide use. Increased heart rate (choice C) is not a direct effect of furosemide and can indicate worsening heart failure. Decreased urine output (choice D) would be an adverse effect of furosemide and would indicate the medication is not working as intended.