Nokea
The nurse is caring for a client who is scheduled for an adrenalectomy. The nurse plans to administer which medication in the preoperative period to prevent Addisonian crisis?
- A. Prednisone orally
- B. Fludrocortisone orally
- C. Spironolactone intramuscularly
- D. Methylprednisolone sodium succinate intravenously
Correct Answer: D
Rationale: A glucocorticoid preparation will be administered intravenously or intramuscularly in the immediate preoperative period to a client scheduled for an adrenalectomy. Methylprednisolone sodium succinate protects the client from developing acute adrenal insufficiency (Addisonian crisis) that can occur as a result of the adrenalectomy. Prednisone is an oral corticosteroid. Fludrocortisone is a mineralocorticoid. Spironolactone is a potassium-sparing diuretic.
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The nurse is caring for a client who is scheduled to have a liver biopsy. Before the procedure, it is important for the nurse to assess which parameter to assure client safety?
- A. Tolerance for pain
- B. Allergy to iodine or shellfish
- C. History of nausea and vomiting
- D. Ability to lie still and hold the breath
Correct Answer: D
Rationale: A liver biopsy is an invasive procedure that involves inserting a needle into the liver to obtain a tissue sample. To ensure client safety, the nurse must assess the client's ability to lie still and hold their breath during the procedure, as movement or breathing can cause complications such as bleeding or injury to surrounding organs. Assessing pain tolerance, allergies to iodine or shellfish, or a history of nausea and vomiting is not directly related to the safety of the liver biopsy procedure.
The nurse is caring for a client scheduled to undergo a renal biopsy. To minimize the risk of postprocedure complications, the nurse reports which laboratory results to the primary health care provider before the procedure?
- A. Prothrombin time: 15 seconds
- B. Potassium: 3.8 mEq/L (3.8 mmol/L)
- C. Serum creatinine: 1.2 mg/dL (106 mcmol/L)
- D. Blood urea nitrogen (BUN): 18 mg/dL (6.48 mmol/L)
Correct Answer: A
Rationale: Postprocedure hemorrhage is a complication after renal biopsy. Because of this, prothrombin time is assessed before the procedure. The normal prothrombin time range is 11 to 12.5 seconds. The nurse ensures that these results are available and reports abnormalities promptly. Options 2, 3, and 4 identify normal values. The normal potassium is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L); the normal serum creatinine is 0.5 to 1.2 mg/dL (44 to 106 mcmol/L); and the normal BUN is 10-20 mg/dL (3.6-7.1 mmol/L).
Which action should the nurse take before performing a venipuncture to initiate continuous intravenous (IV) therapy?
- A. Apply a cool compress to the affected area.
- B. Inspect the IV solution and expiration date.
- C. Secure a padded arm board above the IV site.
- D. Apply a tourniquet below the venipuncture site.
Correct Answer: B
Rationale: IV solutions should be free of particles or precipitates to prevent trauma to veins or a thromboembolic event; in addition, the nurse avoids administering IV solutions whose expiration date has passed to prevent infection. Cool compresses cause vasoconstriction, making the vein less visible, smaller, and more difficult to puncture. Arm boards are applied after the IV is started and are used only if necessary. A tourniquet is applied above the chosen vein site to halt venous return and engorge the vein; this makes the vein easier to puncture.
The nurse is reviewing the laboratory results for a client who is receiving torsemide 5 mg orally daily. What value should indicate to the nurse that the client might be experiencing an adverse effect of the medication?
- A. A chloride level of 98 mEq/L (98 mmol/L)
- B. A sodium level of 135 mEq/L (135 mmol/L)
- C. A potassium level of 3.1 mEq/L (3.1 mmol/L)
- D. A blood urea nitrogen (BUN) level of 15 mg/dL (5.4 mmol/L)
Correct Answer: C
Rationale: Torsemide is a loop diuretic. The medication can produce acute, profound water loss; volume and electrolyte depletion; dehydration; decreased blood volume; and circulatory collapse. Option 3 is the only option that indicates electrolyte depletion because the normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). The normal chloride level is 98 to 107 mEq/L (98 to 107 mmol/L). The normal sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). The normal BUN level ranges from 10 to 20 mg/dL (3.6 to 7.1 mmol/L).
The nurse is monitoring an unconscious client who sustained a head injury. Which observed positioning supports the suspicion that the client sustained an upper brainstem injury?
- A. Abnormal involuntary flexion of the extremities
- B. Abnormal involuntary extension of the extremities
- C. Upper extremity extension with lower extremity flexion
- D. Upper extremity flexion with lower extremity extension
Correct Answer: B
Rationale: Decerebrate posturing, which can occur with upper brainstem injury, is characterized by abnormal involuntary extension of the extremities. Options 1, 3, and 4 are incorrect descriptions of this type of posturing.