Nokea
The nurse is caring for a client who was newly prescribed warfarin. Which medication on the client's medication list requires follow-up with the primary healthcare provider (PHCP)?
- A. Loratadine
- B. Saw Palmetto
- C. Furosemide
- D. Pantoprazole
Correct Answer: B
Rationale: Saw Palmetto can interact with warfarin by potentially increasing bleeding risk due to its antiplatelet effects, requiring follow-up with the PHCP. Loratadine (A), Furosemide (C), and Pantoprazole (D) have minimal interactions with warfarin.
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The nurse has taught a client about a scheduled intravenous (IV) urography (pyelogram). Which of the following statements by the client would indicate a correct understanding of the teaching?
- A. I should expect a temporary urinary catheter inserted during the procedure.
- B. I will take a laxative the night before to clear my bowels.
- C. I must fill my bladder with water immediately before the procedure.
- D. I may experience blood in my urine for a few days after this procedure.
Correct Answer: B
Rationale: A laxative is often required before IV urography to clear the bowels for better imaging.
The nurse cares for a client diagnosed with end-stage renal disease who just returned from initial hemodialysis. Which of the following assessment findings is of the highest concern?
- A. Headache and nausea
- B. Scant blood on the AV fistula
- C. Potassium 3.7 mEq/L (mmol/L) [3.5-5.0 mEq/L, mmol/L]
- D. Hemoglobin 8.8 g/dL [Male: 14-18 g/dL; Female: 12-16 g/dL, Female 115-155 g/L Male 125-170 g/L]
Correct Answer: A
Rationale: Headache and nausea may indicate dialysis disequilibrium syndrome, a serious complication requiring immediate attention.
The following scenario applies to the next 1 items
The nurse in the emergency department (ED) is caring for a 78-year-old female client
Item 1 of 1
Nurses' Note
1355: Client was brought to the ED by the client's adult children, who reported that while she was visiting, she reported dizziness and seemed slightly confused. The adult child reports that the symptoms started one day ago. The client recently had a change in her blood pressure medication, with the physician increasing the dosage of her prescribed furosemide. Medical history of hypertension, hyperlipidemia, and osteoarthritis. Vital signs: T 100° F (37.8° C), P 104, RR 22, BP 110/66, pulse oximetry reading 95% on room air.
On assessment, the client is lethargic and oriented to person and place, but not time. The client's breathing appears unlabored with tachypnea. Clear lung sounds throughout all lung fields. Skin is warm, dry, and flaky. Peripheral pulses 1+ in all extremities. Aching pain reported in the hips and knees and rated 5 on a scale of 0 (no pain) to 10 (severe pain). Client was ambulated to the bathroom, where she urinated 300 mL of clear, yellow urine without any odor or particulates. 22-gauge peripheral venous access device (VAD) placed in right forearm.
Complete the sentence below by choosing from the list of options. Based on the client's..... and............. this client is at highest risk for........
- A. lung sounds
- B. vital signs
- C. pain level
- D. dosage increase of diuretic
- E. urinary infection.
- F. fluid volume deficit.
Correct Answer: B, D,F
Rationale: Increased furosemide dosage increases the risk of fluid volume deficit, as evidenced by dizziness and lethargy.
The nurse in the emergency department (ED) is caring for a 57-year-old male client.
Item 5 of 6
History and Physical
A 57-year-old male client with stage three small cell lung cancer. The client had suddenly become disoriented and did not recognize his family members and relatives. He reports severe lower extremity weakness and has had three episodes of diarrhea in the past four hours. The client is undergoing 6 cycles of chemotherapy with cisplatin and etoposide. He is currently taking a 14-day course of 15 mg of prednisone. He is on his third day of steroid treatment. He has a medical history of dyslipidemia and advanced chronic obstructive pulmonary disease.
Laboratory Results
• Hemoglobin 14 g/dL [14-18 g/dL (140–180 g/L)]
• Hematocrit 42% (0.42) [42-52% (0.42-0.52)]
• White Blood Cell 11,000 mm3 [5-10 mm3]
• Platelet Count 140,000 mm3 [150-400 mm3 (150–400 × 109/L)]
• Glucose 139 mg/dL (7.72 mmol/L) [70–110 mg/dL (4-6 mmol/L)]
• Sodium 116 mEq/L [136–145 mEq/L (mmol/L)]
• Potassium 3.3 mEq/L [3.5–5.0 mEq/L (mmol/L)]
• Creatinine 0.7 mg/dL (61.88 mmol/L) [0.6–1.2 mg/dL (53–106 mmol/L)]
• Blood Urea Nitrogen 8 mg/dL (2.86 mmol/L) [10–20 mg/dL (3.6–7.1 mmol/L)]
• Serum Osmolality 277 mOsm/kg [285-295 mOsm/kg (285–295 mmol/kg)]
Nurses' Notes
0759: Client is completely disoriented and required maximum assistance to the stretcher because of unsteady gait. Lung sounds clear bilaterally. Alopecia noted. Skin is warm and dry and normal for ethnicity. Peripheral pulses 2+. No skin tenting. Hyperactive bowel sounds in all quadrants. 20-gauge peripheral vascular access device placed in the left antecubital space. T 97.8° F (36.6° C) P 88 RR 21 BP 123/68 Pulse oximetry reading 91% on room air.
0850: Verbal order was received from physician to insert indwelling urethral catheter.
0910: Urinary catheter inserted with sterile technique. 40 mL of dark yellow urine returned.
Orders
• admit to intensive care unit
• nephrology consultation
• oncology consultation
• fluid restriction - 1 liter daily
• daily weight
• strict intake and output
• 250 mL of 3% saline at 75 mL/hr
• tolvaptan 15 mg PO daily - first dose now
• neurological assessments every two hours
The nurse reviews the orders and prepares to administer the first dose of prescribed tolvaptan. Complete the following sentences by choosing from the lists of options. Prior to administering the first dose of this medication, the nurse should obtain an order to review the client's baseline.............. as.......................... is a serious adverse effect of this medication? Osmotic demyelination syndrome is another serious adverse reaction to this medication and requires monitoring of the client's.................
- A. liver enzymes
- B. thyroid toxicity
- C. liver injury
- D. myocardial infarction
- E. urinary output.
- F. Glasgow coma scale.
- G. blood pressure.
Correct Answer: A,F
Rationale: Tolvaptan can cause liver injury, requiring baseline liver enzyme monitoring. Osmotic demyelination syndrome requires neurological monitoring via Glasgow Coma Scale.
The following scenario applies to the next 1 items
The medical-surgical nurse is caring for a 67-year-old client
Item 1 of 1
Nurses’ Note
1535: Client returned from hemodialysis via stretcher to assigned room. The client was alert, oriented x 4. Denied any pain. He stated he felt ‘tired and dizzy.’ The client reported that the dizziness occurred when he quickly changed positions. The client was assessed, and vital signs were obtained.
Vital Signs
• Temperature 97° F (36° C)
• Pulse 94/minute; irregular
• Respirations 14/minute
• Blood Pressure 91/58 mm Hg
• Oxygen saturation 92% on room air
Assessment
Neurological:
Alert and completely oriented; reports dizziness. Pupils, equal, round, and reactive to light.
Cardiovascular:
Peripheral pulses intact; no edema; S1/S2 heart tones. Positive bruit and thrill in left arm A/V fistula. Gauze dressing applied which is dry with a scant amount of dry blood
Respiratory:
Diminished lung sounds, occasional cough
GI/GU:
Normoactive bowel sounds in all quadrants. Anuria.
Skin:
Warm and dry
Medical History
• End-stage renal disease (ESRD)
• Uncontrolled hypertension
• Chronic obstructive pulmonary disease
• Atrial fibrillation
The nurse reviews the nursing note, vital signs, assessment, and medical history. Which clinical data is most concerning to the nurse? Select all that apply.
- A. A/V fistula assessment
- B. Oxygen saturation
- C. Pulse
- D. Blood pressure
- E. Neurological assessment
- F. Temperature
- G. Anuria
Correct Answer: C,D,E,G
Rationale: Irregular pulse, low blood pressure (91/58 mmHg), dizziness, and anuria indicate potential cardiovascular and renal complications post-hemodialysis.