Nokea
The nurse is caring for a patient who is taking trimethoprim-sulfamethoxazole (TMP-SMX). The nurse learns that the patient takes an angiotensin-converting enzyme (ACE) inhibitor. To monitor for drug interactions, the nurse will request an order for which laboratory test(s)?
- A. A complete blood count
- B. BUN and creatinine
- C. Electrolytes
- D. Glucose
Correct Answer: C
Rationale: The correct answer is 'C. Electrolytes.' When trimethoprim-sulfamethoxazole (TMP-SMX) is taken with an ACE inhibitor, there is an increased risk of hyperkalemia due to the combined effects on potassium levels. Monitoring electrolytes, specifically potassium, is essential to detect and manage this potential drug interaction. Choices A, B, and D are incorrect because while they are important tests in general patient care, they are not specifically indicated to monitor for the drug interaction between TMP-SMX and ACE inhibitors.
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After a renal biopsy, which intervention should the nurse include in the post-procedure plan of care?
- A. Restricting fluid intake for the first 24 hours
- B. Periodically testing the urine for occult blood
- C. Avoiding the administration of opioid analgesics
- D. Having the client ambulate in the room and hall for short distances
Correct Answer: B
Rationale: After a renal biopsy, it is essential to maintain bed rest and frequently assess the client's vital signs and the puncture site. The nurse should test the urine periodically for occult blood to detect any bleeding, which could be a complication of the procedure. Restricting fluid intake for the first 24 hours is not necessary after a renal biopsy and could potentially lead to dehydration. Avoiding the administration of opioid analgesics is not a standard intervention post-renal biopsy unless contraindicated for a specific reason. Having the client ambulate in the room and hall for short distances is generally not recommended immediately after a renal biopsy due to the need for bed rest to prevent complications.
A nurse has a prescription to discontinue a client's nasogastric tube. The nurse auscultates the client's bowel sounds, positions the client properly, and flushes the tube with 15 mL of air to clear secretions. The nurse then instructs the client to take a deep breath and:
- A. Exhale during tube removal
- B. Bear down during tube removal
- C. Hold the breath during tube removal
- D. Breathe normally during tube removal
Correct Answer: C
Rationale: The correct answer is to instruct the client to hold their breath during tube removal. This is because the airway may be temporarily obstructed during the removal process. By holding their breath, the client can help prevent aspiration or discomfort during the removal of the nasogastric tube. Choices A, B, and D are incorrect because exhaling, bearing down, or breathing normally during tube removal may not provide the necessary protection against aspiration or discomfort that holding the breath does.
A nurse obtains a sterile urine specimen from a client's Foley catheter. After applying a clamp to the drainage tubing distal to the injection port, which action should the nurse take next?
- A. Clamp another section of the tube to create a fixed sample section for retrieval.
- B. Insert a syringe into the injection port and aspirate the quantity of urine required.
- C. Clean the injection port cap of the drainage tubing with a povidone-iodine solution.
- D. Withdraw 10 mL of urine and discard it; then withdraw a fresh sample of urine.
Correct Answer: C
Rationale: The correct next action for the nurse to take after applying a clamp to the drainage tubing distal to the injection port is to clean the injection port cap of the catheter drainage tubing with an appropriate antiseptic like povidone-iodine solution or alcohol. This step is crucial to prevent surface contamination before taking the urine sample. Clamping another section of the tube to create a fixed sample section or withdrawing and discarding urine are unnecessary and could lead to potential contamination. Inserting a syringe into the injection port and aspirating the required amount of urine directly from the catheter is the correct method for obtaining the urine sample, but cleaning the injection port cap should precede this step to ensure sterility.
A client is being prepared for transfer to the operating room. Which of the following actions should the nurse take in the care of this client at this time?
- A. Ensuring that the client has voided
- B. Administering all daily medications
- C. Practicing postoperative breathing exercises
- D. Verifying that the client has not eaten for the last 24 hours
Correct Answer: A
Rationale: The nurse should ensure that the client has voided, especially if a Foley catheter is not in place. This step is important to prevent urinary retention during the surgical procedure. Administering all daily medications just before surgery is not standard practice. The physician typically provides specific orders regarding which medications can be taken with a sip of water before surgery. Postoperative breathing exercises are usually taught after surgery to prevent complications like atelectasis. Verifying that the client has not eaten for the last 24 hours is not a standard preoperative practice; instead, the client is usually instructed to fast for a specific period before surgery to reduce the risk of aspiration during anesthesia.
After teaching a client with renal cancer who is prescribed temsirolimus (Torisel), the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching?
- A. I will take this medication with food and plenty of water.
- B. I shall keep my appointment at the infusion center each week.
- C. I'll limit my intake of green leafy vegetables while on this medication.
- D. I must not take this medication if I have an infection or am feeling ill.
Correct Answer: B
Rationale: The correct answer is B. Temsirolimus, also known as Torisel, is administered as a weekly intravenous infusion. This medication blocks protein needed for cell division, inhibiting cell cycle progression. It is not taken orally, so there is no need to take it with food or water. Keeping the weekly infusion center appointment is crucial for the client to receive the prescribed treatment effectively. Choice A is incorrect as temsirolimus is not taken with food or water. Choice C is incorrect because there is no need to limit the intake of green leafy vegetables while on this medication. Choice D is incorrect as having an infection or feeling ill does not prohibit the use of temsirolimus.