Nokea
The nurse is assessing a client with complaints of vague upper abdominal pain worse at night but relieved by sitting up and leaning forward. Which assessment question should the nurse ask next?
- A. Have you noticed a yellow haze when you look at things?
- B. Does the pain get worse when you eat a meal or snack?
- C. Have you had your amylase and lipase checked recently?
- D. How much weight have you gained since you saw an HCP?
Correct Answer: A
Rationale: The pain description suggests pancreatic cancer; jaundice (yellow haze) is a common symptom due to bile duct obstruction, guiding further assessment. Eating effects, labs, and weight gain are less specific.
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The client taking thyroid replacement hormone is hospitalized, and a thyroid replacement hormone is not prescribed. A week after being hospitalized, the nurse assesses that the client is becoming increasingly lethargic and has a decreased blood pressure, respiratory rate, temperature, and pulse. Which actions should be taken by the nurse? Place each nursing action in the order of priority.
- A. Warm the client
- B. Administer intravenous fluids
- C. Assist in ventilatory support
- D. Administer thyroxine as prescribed
Correct Answer: C,B,A,D
Rationale: Ventilatory support addresses decreased respiratory rate, IV fluids treat hypotension, warming prevents metabolic demand increase, and thyroxine corrects hypothyroidism.
Which client statement indicates a correct understanding of corticosteroid therapy for Addison's disease?
- A. I can stop the medication if I feel better.
- B. I need to take this medication daily.
- C. I should take it only during stress.
- D. I can double the dose if I'm sick.
Correct Answer: B
Rationale: Corticosteroid therapy for Addison's disease requires daily administration to replace deficient hormones and maintain physiological balance.
Based on the client's blood glucose measurement, the nurse immediately reevaluates the client. Which physician orders should the nurse anticipate? Select all that apply.
- A. STAT serum blood glucose
- B. Intravenous regular insulin
- C. Vital signs every 2 hours
- D. A diet of six small, frequent meals
- E. Electronic glucometer measurements before meals and at bedtime
- F. Continuous cardiac monitoring
Correct Answer: A,B,E,F
Rationale: DKA with a glucose of 498 mg/dL requires STAT serum glucose, IV insulin, frequent glucometer checks, and cardiac monitoring.
The nurse is admitting the client tentatively diagnosed with possible hyperaldosteronism. What should be the nurse's priority?
- A. Prepare for a computed tomography (CT) scan
- B. Give prn prescribed analgesic to treat headache
- C. Obtain an ECG to evaluate for dysrhythmias
- D. Assess for generalized weakness and fatigue
Correct Answer: C
Rationale: Obtaining an ECG is priority to detect dysrhythmias from hypokalemia caused by potassium wasting in hyperaldosteronism.
The health-care provider has ordered 40 g/24 hr of intranasal vasopressin for a client diagnosed with diabetes insipidus. Each metered spray delivers 10 g. The client takes the medication every 12 hours. How many sprays are delivered at each dosing time?
Correct Answer: 2 sprays
Rationale: Total dose: 40 g/24 hr, split every 12 hr = 20 g/dose. Each spray = 10 g, so 20 g ÷ 10 g/spray = 2 sprays per dose.