Nokea
The nurse is caring for a client who is receiving tacrolimus daily. Which finding indicates to the nurse that the client is experiencing an adverse effect of the medication?
- A. Hypotension
- B. Photophobia
- C. Profuse sweating
- D. Decrease in urine output
Correct Answer: D
Rationale: Tacrolimus is an immunosuppressant medication used in the prophylaxis of organ rejection in clients receiving allogenic liver transplants. Adverse reactions and toxic effects include nephrotoxicity and pleural effusion. Nephrotoxicity is characterized by an increasing serum creatinine level and a decrease in urine output. Frequent side effects include headache, tremor, insomnia, paresthesia, diarrhea, nausea, constipation, vomiting, abdominal pain, and hypertension. None of the other options are associated with an adverse reaction to this medication.
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A client is diagnosed with diabetes insipidus. The nurse should plan interventions to address which manifestations of this disorder? Select all that apply.
- A. Bradycardia
- B. Hypertension
- C. Poor skin turgor
- D. Increased urinary output
- E. Dry mucous membranes
- F. Decreased pulse pressure
Correct Answer: C,D,E,F
Rationale: Diabetes insipidus is a water metabolism problem caused by an antidiuretic hormone (ADH) deficiency (either a decrease in ADH synthesis or an inability of the kidneys to respond to ADH). Clinical manifestations include poor skin turgor, increased urinary output, dry mucous membranes, decreased pulse pressure, tachycardia, hypotension, weak peripheral pulses, and increased thirst.
The nurse is caring for a client diagnosed with preeclampsia. When the client's condition progresses from preeclampsia to eclampsia, what should the nurse's first action be?
- A. Maintain an open airway.
- B. Administer oxygen by face mask.
- C. Assess the maternal blood pressure and fetal heart tones.
- D. Administer an intravenous infusion of magnesium sulfate.
Correct Answer: A
Rationale: Eclampsia is characterized by the occurrence of seizures. If the client experiences seizures, it is important as a first action to establish and maintain an open airway and prevent injuries to the client. Options 2, 3, and 4 are all interventions that should be done but not initially.
To assure the desired results, how should the nurse instruct the client prescribed oral bisacodyl to take the medication?
- A. At bedtime
- B. With a large meal
- C. With a glass of milk
- D. On an empty stomach
Correct Answer: A
Rationale: Bisacodyl is a stimulant laxative that works by stimulating peristalsis in the colon. To ensure its effectiveness, it should be taken at bedtime to produce a bowel movement in the morning, typically 6 to 12 hours after administration. Taking it with a large meal or milk may reduce its effectiveness due to delayed gastric emptying or interaction with food. Taking it on an empty stomach may cause stomach irritation and is not necessary for its action.
The nurse caring for a client after right radical mastectomy includes which intervention in the nursing plan of care for this client?
- A. Takes blood pressures in the right arm only
- B. Draws serum laboratory samples from the right arm only
- C. Positions the client supine and flat with the right arm elevated on a pillow
- D. Checks the right posterior axilla area when assessing the surgical dressing
Correct Answer: D
Rationale: If there is drainage or bleeding from the surgical site after mastectomy, gravity will cause the drainage to seep down and soak the posterior axillary portion of the dressing first. The nurse checks this area to detect early bleeding. Blood pressure measurement, venipuncture, and intravenous sites should not involve use of the operative arm. The client should be positioned with the head in semi-Fowler's position and the arm on the operative side elevated on pillows to decrease edema.
The nurse is planning to give a tepid tub bath to a child experiencing hyperthermia. Which action should the nurse plan to perform?
- A. Obtain isopropyl alcohol to add to the bath water.
- B. Allow 5 minutes for the child to soak in the bath water.
- C. Have cool water available to add to the warm bath water.
- D. Warm the water to the same body temperature as the child's.
Correct Answer: C
Rationale: Adding cool water to an already warm bath allows the water temperature to slowly drop. The child is able to gradually adjust to the changing water temperature and will not experience chilling. Alcohol is toxic, can cause peripheral vasoconstriction, and is contraindicated for tepid sponge or tub baths. The child should be in a tepid tub bath for 20 to 30 minutes to achieve maximum results. To achieve the best cooling results, the water temperature should be at least 2 degrees lower than the child's body temperature.