Nokea
The nurse is caring for a client with a history of burns. Which of the following complications should the nurse monitor for? Select all that apply.
- A. Sepsis.
- B. Hypovolemia.
- C. Hyperkalemia.
- D. Respiratory distress.
- E. Hypoglycemia.
Correct Answer: A, B, C, D
Rationale: Burns can cause sepsis (infection), hypovolemia (fluid loss), hyperkalemia (tissue damage), and respiratory distress (inhalation injury).
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A client has begun medication therapy with pancrelipase. The nurse should educate the client to expect which occurrence from this medication?
- A. Relieve of heartburn
- B. Eliminate of abdominal pain
- C. Help regulating blood glucose
- D. Decrease in the amount of fat in the stools
Correct Answer: D
Rationale: Pancrelipase is a pancreatic enzyme used in clients with pancreatitis as a digestive aid. The medication should reduce the amount of fatty stools (steatorrhea). Another intended effect could be improved nutritional status. It is not used to treat abdominal pain or heartburn. It does not regulate blood glucose; this is a function of insulin, a hormone produced in the beta cells of the pancreas.
A client with a history of hypothyroidism is prescribed levothyroxine (Synthroid). The nurse should instruct the client to:
- A. Take the medication at bedtime.
- B. Avoid taking the medication with grapefruit juice.
- C. Take the medication with a high-fiber meal.
- D. Stop the medication if palpitations occur.
Correct Answer: B
Rationale: Grapefruit juice can interfere with levothyroxine absorption, so it should be avoided.
Which action by the new nurse when initiating continuous electrocardiogram (ECG) monitoring on a client should indicate to the registered nurse the need for further teaching?
- A. Clipping small areas of hair under the area planned for electrode placement
- B. Stating the need to change the electrodes and inspect the skin every 24 hours
- C. Stating the need to use hypoallergenic electrodes for clients who are sensitive
- D. Cleansing the skin with povidone-iodine (Betadine) before applying the electrodes
Correct Answer: D
Rationale: The skin is cleansed with soap and water (not povidone-iodine), denatured with alcohol, and allowed to air-dry before electrodes are applied. The other three options are correct measures.
The nurse coordinates with the laboratory staff to have the gentamicin trough serum level drawn. At what time should the blood be drawn in relation to the administration of the I.V. dose of gentamicin sulfate [Garamycin]?
- A. 2 hours before the administration of the next I.V. dose.
- B. 3 hours before the administration of the next I.V. dose.
- C. 4 hours before the administration of the next I.V. dose.
- D. Just before the administration of the next I.V. dose.
Correct Answer: D
Rationale: The trough level, which measures the lowest drug concentration, is drawn just before the next dose to ensure the drug is within a therapeutic range and to avoid toxicity.
A client with a history of renal calculi is prescribed allopurinol (Zyloprim). The nurse should instruct the client to:
- A. Increase fluid intake.
- B. Avoid dairy products.
- C. Take the medication with meals.
- D. Stop the medication if pain resolves.
Correct Answer: A
Rationale: Increased fluid intake prevents stone formation while taking allopurinol for uric acid stones.