Nokea
The nurse is caring for a client who has influenza. Which of the following prescriptions may be prescribed by the primary healthcare provider (PHCP)?
- A. Valacyclovir
- B. Oseltamivir
- C. Azithromycin
- D. Omeprazole
Correct Answer: B
Rationale: Oseltamivir is an antiviral medication used to treat influenza. Choice A (valacyclovir) is for herpes, Choice C (azithromycin) is an antibiotic, and Choice D (omeprazole) is a proton pump inhibitor, none of which treat influenza.
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The goal of nursing care for a client with acute myeloid leukemia (AML) is to prevent:
- A. Cardiac arrhythmias.
- B. Liver failure.
- C. Renal failure.
- D. Hemorrhage.
Correct Answer: D
Rationale: AML causes pancytopenia, including thrombocytopenia, increasing the risk of hemorrhage. Preventing bleeding is a primary nursing goal through measures like avoiding invasive procedures and monitoring for bleeding signs. Arrhythmias, liver, and renal failure are less immediate concerns.
Following a transsphenoidal hypophysectomy, the nurse should assess the client for:
- A. Cerebrospinal fluid (CSF) leak.
- B. Fluctuating blood glucose levels.
- C. Cushing's syndrome.
- D. Cardiac arrhythmias.
Correct Answer: A
Rationale: A CSF leak is a potential complication of transsphenoidal hypophysectomy due to the surgical approach through the sphenoid sinus, requiring careful monitoring.
The client is scheduled for an intravenous pyelogram (IVP) to determine the location of the renal calculi. Which of the following measures would be most important for the nurse to include in pretest preparation?
- A. Ensuring adequate fluid intake on the day of the test.
- B. Preparing the client for the possibility of bladder, the client is history for allergy to iodine.
- C. Determining when the client last had a bowel movement.
Correct Answer: B
Rationale: Checking for iodine allergy is critical for IVP due to the use of iodine-based contrast, which can cause severe allergic reactions.
A client's serum ammonia level is elevated, and the physician orders 30 mL of lactulose (Cephulac). Which of the following is an adverse effect of this drug?
- A. Increased urine output.
- B. Improved level of consciousness.
- C. Increased bowel movements.
- D. Nausea and vomiting.
Correct Answer: C
Rationale: Lactulose promotes bowel movements (C) to excrete ammonia, a common adverse effect. Urine output (A) and consciousness (B) are not adverse effects. Nausea (D) is less common.
A 70-year-old male with the diagnosis of claudication has been hospitalized for an evaluation of his increasingly impaired mobility and complaints of pain. The client tells the nurse that he can no longer walk a block without having severe pain in his left calf and foot. Based on these data, which nursing diagnosis would be most appropriate for this client?
- A. Activity intolerance related to decreased blood supply and pain
- B. Self-care deficit related to increased leg pain
- C. Ineffective coping related to chronic pain
- D. Impaired skin integrity related to poor circulation
Correct Answer: A
Rationale: Activity intolerance due to decreased blood supply and pain is the most appropriate nursing diagnosis, as claudication (pain during walking) directly results from inadequate arterial blood flow, limiting mobility. The other diagnoses may apply but are less specific to the described symptoms.