Nokea
The nurse is assessing the laboratory test results for the male client receiving testosterone replacement therapy for treatment of hypogonadism. Which laboratory test result is most important for the nurse to review?
- A. Fasting lipid profile
- B. Partial thromboplastin time
- C. Urinalysis
- D. Serum potassium
Correct Answer: A
Rationale: A: The most important test is the fasting lipid profile because testosterone can lower plasma levels of HDLs and elevate plasma levels of LDLs, increasing the risk of atherosclerosis. B: Testosterone has little effect on PTT. C: Testosterone has little effect on urine. D: Testosterone has little effect on serum potassium.
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Which of the following is true when administering a nasal spray medication?
- A. The client should blow their nose gently before the medication is administered.
- B. The medication should be sprayed in front of the nose.
- C. The medication should be administered as the patient exhales.
- D. The client should lay flat when the medication is administered.
Correct Answer: A
Rationale: The client should blow their nose gently before the medication is administered. This is to clear the nasal passages to allow the medication to be properly administered. When administering the medication, the client should sit upright, insert the applicator into the designated nostril, and spray the medication as the patient inhales.
The client diagnosed with BPD is taking Olanzapine. The nurse evaluates that Olanzapine is effective when observing a reduction in which behaviors? Select all that apply.
- A. Levels of anxiety
- B. The use of splitting
- C. Thoughts of paranoia
- D. Feelings of depression
- E. Expression of hostility
Correct Answer: A,C,E
Rationale: With BPD, reductions in anxiety, paranoia, and hostility indicate olanzapine (Zyprexa) is effective.
A woman is in the active phase of labor. An external monitor has been applied, and a fetal heart deceleration of uniform shape is observed, beginning just as the contraction is under way and returning to the baseline at the end of the contraction. Which of the following nursing actions is most appropriate?
- A. Administer O2.
- B. Turn the client on her left side.
- C. Notify the physician.
- D. No action is necessary.
Correct Answer: D
Rationale: It is an early deceleration as a result of head compression, and at this time no action is necessary. Close observation of the mother and baby is needed.
The nurse is observing a client self-administer two medications that are in a crushable pill form through their G tube. Which of the following would indicate a need for further instruction?
- A. The client flushes the G-tube before administering the medications, in between the two medications, and after the medications.
- B. The client states they will remain in the Semi-Fowler's position for 30 minutes following administration of the medications.
- C. The client mixes their medications with their tube-feeding formula.
- D. The client mixes each medication separately in warm water.
Correct Answer: C
Rationale: Medication should not be mixed with tube-feeding formula or other medications. The G-tube should be flushed before, between, and after the medications, and the client should remain in the Semi-Fowler's position for at least 30 minutes after medications are administered.
The client has been prescribed clonidine for the unlabeled purpose of easing the discomfort associated with smoking cessation. Which body system should be the nurse's initial focus when completing the client's physical assessment?
- A. Neurological
- B. Cardiovascular
- C. Gastrointestinal
- D. Musculoskeletal
Correct Answer: B
Rationale: Clonidine (Catapres) can cause hypotension and bradycardia, making the cardiovascular system the initial focus.