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The nurse is caring for a client who is receiving cyclosporine. Which condition indicates to the nurse that the client is experiencing an adverse effect of the medication?
- A. Acne
- B. Sweating
- C. Joint pain
- D. Hyperkalemia
Correct Answer: D
Rationale: Cyclosporine is an immunosuppressant medication used in the prophylaxis of organ rejection. Adverse effects include nephrotoxicity, infection, hepatotoxicity, hypomagnesemia, coma, hypertension, tremor, and hirsutism. Additionally, neurotoxicity, gastrointestinal effects, hyperkalemia, and hyperglycemia can occur. Options 1, 2, and 3 are not associated with this medication.
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The nurse admits a client who is bleeding freely from a scalp laceration that resulted from a fall. The nurse should take which action first in the care of this wound?
- A. Prepare for suturing the area.
- B. Determine when the client last had a tetanus vaccine.
- C. Cleanse the wound by flushing with sterile normal saline.
- D. Apply direct pressure to the laceration to stop the bleeding.
Correct Answer: D
Rationale: In the presence of active bleeding from a scalp laceration, the priority is to control the bleeding to prevent further blood loss and stabilize the client. Applying direct pressure to the laceration is the most effective initial action to achieve this. Preparing for suturing, determining tetanus vaccine status, and cleansing the wound are important but secondary actions that follow after bleeding is controlled.
A client arrives at the emergency department with upper gastrointestinal (GI) bleeding that began 3 hours ago. What is the priority action?
- A. Obtaining vital signs
- B. Inserting a nasogastric (NG) tube
- C. Asking the client about the precipitating events
- D. Completing an abdominal physical assessment
Correct Answer: A
Rationale: The priority action for the client with GI bleeding is to obtain vital signs to determine whether the client is in shock from blood loss and obtain a baseline by which to monitor the progress of treatment. The client may not be able to provide subjective data until the immediate physical needs are met. A complete abdominal physical assessment must be performed but is not the priority. Insertion of an NG tube may be prescribed but is not the priority action.
A client has been admitted with a diagnosis of acute glomerulonephritis. During history taking, the nurse should ask the client about a recent history of which event?
- A. Bleeding ulcer
- B. Myocardial infarction
- C. Deep vein thrombosis
- D. Streptococcal infection
Correct Answer: D
Rationale: The predominant cause of acute glomerulonephritis is infection with beta-hemolytic Streptococcus 3 weeks before the onset of symptoms. In addition to bacteria, other infectious agents that could trigger the disorder include viruses, fungi, and parasites. Bleeding ulcer, myocardial infarction, and deep vein thrombosis are not precipitating causes.
A client who has sustained a burn injury receives a prescription for a regular diet. Which is the best meal for the nurse to provide to the client to promote wound healing?
- A. Peanut butter and jelly sandwich, apple, tea
- B. Chicken breast, broccoli, strawberries, milk
- C. Veal chop, boiled potatoes, Jell-O, orange juice
- D. Pasta with tomato sauce, garlic bread, ginger ale
Correct Answer: B
Rationale: The meal with the best potential to promote wound healing includes nutrient-rich food choices, including protein, such as chicken and milk, and vitamin C, such as broccoli and strawberries. The remaining options include one or more items with a low nutritional value, especially the tea, jelly, Jell-O, and ginger ale.
The nurse is assessing a 3-day-old preterm neonate with a diagnosis of respiratory distress syndrome (RDS). Which assessment finding indicates that the neonate's respiratory condition is improving?
- A. Edema of the hands and feet
- B. Urine output of 3 mL/kg/hour
- C. Presence of a systolic murmur
- D. Respiratory rate between 60 and 70 breaths per minute
Correct Answer: B
Rationale: RDS is a serious lung disorder caused by immaturity and the inability to produce surfactant, resulting in hypoxia and acidosis. Lung fluid, which occurs in RDS, moves from the lungs into the bloodstream as the condition improves and the alveoli open. This extra fluid circulates to the kidneys, which results in increased voiding. Therefore, normal urination is an early sign that the neonate's respiratory condition is improving (normal urinary output is 2 to 5 mL/kg/hour). Edema of the hands and feet occurs within the first 24 hours after the development of RDS as a result of low protein concentrations, a decrease in colloidal osmotic pressure, and transudation of fluid from the vascular system to the tissues. Systolic murmurs usually indicate the presence of a patent ductus arteriosus, which is a common complication of RDS. Respiratory rates above 60 are indicative of tachypnea, which is a sign of respiratory distress.