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The nurse is caring for a client who has acute pancreatitis. Based on the 11:15 AM vital signs, the nurse should prioritize which action? Click to view the exhibit for additional client information.
- A. Obtain a 12-lead electrocardiogram
- B. Assess the client for pain
- C. Apply oxygen via nasal cannula
- D. Infuse 500 ml 0.9% sodium chloride (normal saline) bolus
Correct Answer: B
Rationale: Acute pancreatitis causes severe pain, a hallmark symptom. Without vital signs data, pain assessment is the priority to guide treatment and comfort, preceding ECG, oxygen, or fluids.
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The nurse is caring for a client with Addison's disease. Which statement, if made by the client, would require follow-up?
- A. I started using table salt instead of salt substitutes.
- B. I joined a gym to train for an upcoming marathon.
- C. I recently started wearing a MedicAlert bracelet.
- D. If I start to feel ill, I should call my doctor right away.
Correct Answer: B
Rationale: Addison's causes weakness and hypotension; marathon training is excessive and risky, requiring follow-up. Salt use, MedicAlert, and calling the doctor are appropriate.
The nurse is planning a staff education program about conditions that increase cortisol levels. Which of the following conditions should the nurse include?
- A. Addison's disease
- B. Congestive heart failure (CHF)
- C. Renal failure
- D. Cushing's disease
Correct Answer: D
Rationale: Cushing's disease increases cortisol due to excess ACTH. Addison's reduces cortisol, and CHF and renal failure do not directly elevate cortisol levels.
The nurse is caring for a client who has nephrogenic diabetes insipidus. Which of the following medications should the nurse expect to be prescribed for the client?
- A. prednisone
- B. hydrochlorothiazide
- C. verapamil
- D. lithium
Correct Answer: B
Rationale: Nephrogenic diabetes insipidus reduces kidney response to ADH. Hydrochlorothiazide paradoxically reduces urine output by increasing sodium excretion, concentrating urine. Prednisone, verapamil, and lithium are unrelated or worsen DI.
The nurse is caring for a client who is receiving newly prescribed prednisone. Which of the following medications should the client avoid while receiving this medication?
- A. valsartan
- B. naproxen
- C. omeprazole
- D. acetaminophen
Correct Answer: B
Rationale: Naproxen, an NSAID, should be avoided with prednisone due to increased risk of gastrointestinal bleeding and ulceration. Valsartan, omeprazole, and acetaminophen are generally safe with prednisone, though monitoring is needed.
The nurse is caring for a client diagnosed with hyperparathyroidism. Which laboratory data would support this diagnosis?
- A. Potassium 4.1 mEq/L (mmol/L) [3.5-5 mEq/L, mmol/L]
- B. Phosphorus 4.9 mEq/L (mmol/L) [2-4.5 mEq/L, 0.81-1.58 mmol/L]
- C. Calcium 11.2 mg/dL (2.8 mmol/L) [9-10.5 mg/dL, 2.12-2.52 mmol/L]
- D. Sodium 132 mEq/L (mmol/L) [135-145 mEq/L, mmol/L]
Correct Answer: C
Rationale: Hyperparathyroidism increases PTH, raising blood calcium (11.2 mg/dL is elevated) and often lowering phosphorus. Potassium and sodium are not directly affected.