Nokea
The nurse is caring for a client who has been prescribed infusions of amphotericin b. Which laboratory data is necessary for the nurse to monitor during treatment?
- A. Triglycerides
- B. Hemoglobin A1C
- C. Potassium
- D. High-density lipoprotein (HDL)
Correct Answer: C
Rationale: Amphotericin B can cause electrolyte imbalances, particularly hypokalemia, so monitoring potassium levels (Choice C) is essential. Choices A (triglycerides), B (hemoglobin A1C), and D (HDL) are not directly affected by amphotericin B and are not routinely monitored during treatment.
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A client who has been diagnosed with bladder cancer is scheduled for an ileal conduit. Preoperatively, the nurse reinforces the client's understanding of the surgical procedure by explaining that an ileal conduit:
- A. Is a temporary procedure that can be reversed later.
- B. Diverts urine into the sigmoid colon, where it is expelled through the rectum.
- C. Conveys urine from the ureters to a stoma opening on the abdomen.
- D. Creates an opening in the bladder that allows urine to drain into an external pouch.
Correct Answer: C
Rationale: An ileal conduit diverts urine from the ureters to an abdominal stoma, where it is collected in an external pouch, a permanent procedure for bladder cancer management.
A client has been admitted with acute renal failure. What should the nurse do? Select all that apply.
- A. Elevate the head of the bed 30 to 45 degrees.
- B. Take vital signs.
- C. Establish an I.V. access site.
- D. Call the admitting physician for orders.
- E. Contact the hemodialysis unit.
Correct Answer: B,C,D
Rationale: Taking vital signs, establishing IV access, and contacting the physician are immediate actions to assess and stabilize the client with acute renal failure.
Which of the following adverse effects would the nurse expect the client to exhibit in the event of too rapid an infusion of TPN solution?
- A. Negative nitrogen balance.
- B. Circulatory overload.
- C. Hypoglycemia.
- D. Hypokalemia.
Correct Answer: B
Rationale: Too rapid an infusion of TPN can cause circulatory overload due to the high volume and osmolarity of the solution. Negative nitrogen balance, hypoglycemia, or hypokalemia are not directly caused by rapid infusion. CN: Pharmacological and parenteral therapies; CL: Analyze
When using a Doppler instrument to assess peripheral pulses, the correct placement of the transducer is important because it is difficult to differentiate between:
- A. Arterial and capillary blood flow
- B. Arterial and venous blood flow
- C. Arterial and arteriole blood flow
- D. Capillary and venous blood flow
Correct Answer: B
Rationale: Doppler ultrasound can detect both arterial (pulsatile) and venous (continuous) blood flow, but incorrect transducer placement may confuse these signals. Differentiating arterial from venous flow is critical in PVD assessment to confirm arterial patency. Capillary or arteriole flow is less relevant in this context.
When planning to move a person with a possible spinal cord injury, the nurse should direct the team to:
- A. Limit movement of the arms by wrapping them next to the body.
- B. Move the person gently to help reduce pain.
- C. Immobilize the head and neck to prevent further injury.
- D. Cushion the back with pillows to ensure comfort.
Correct Answer: C
Rationale: Immobilizing the head and neck prevents exacerbation of a spinal cord injury during movement.