Nokea
The nurse is caring for a patient who is undergoing a water deprivation test. Which of the following findings is most important for the nurse to communicate to the health care provider?
- A. Intense thirst
- B. 2.3 kg weight loss
- C. Orthostatic hypotension
- D. No change in urine osmolality
Correct Answer: B
Rationale: A drop in the weight of more than 2 kg indicates severe dehydration, and the test should be discontinued. The other assessment data are not unusual with this test.
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The nurse is teaching a patient how to prepare for an oral glucose tolerance test (OGTT). Which of the following patient response indicates that the teaching has been effective?
- A. Fast 12 hours before the procedure
- B. Clear fluid diet 12 hours prior to the test
- C. Drink only full fluids 6 hours before the test
- D. No fluid or food restrictions prior to the test
Correct Answer: A
Rationale: Fasting for 12 hours before the procedure demonstrates that teaching has been effective. The patient is to be NPO 12 hours prior to the test. A clear fluid diet 12 hours pretest is not indicated. A full fluid diet 6 hours pretest is not indicated.
The regulation of oxytocin during childbirth is an example of which of the following mechanisms?
- A. Physiological rhythm
- B. Secondary input
- C. Loop regulation
- D. Positive feedback
Correct Answer: D
Rationale: An example of the regulation of oxytocin during childbirth is an example of positive feedback. The positive feedback mechanism increases the target organ action beyond normal. The release of oxytocin is stimulated by pressure receptors in the vagina. As the fetus enters the vagina during childbirth, the pressure receptors sense increased pressure and signal the brain to release more oxytocin.
The nurse is evaluating the laboratory results for a patient who has increased secretion of the anterior pituitary hormones. Which of the following findings should the nurse anticipate when reviewing the laboratory findings?
- A. Decreased serum thyroxine levels
- B. Elevated serum aldosterone levels
- C. An increase in urinary free cortisol
- D. Low urinary excretion of catecholamines
Correct Answer: C
Rationale: Increased secretion of adrenocorticotropic hormone (ACTH) by the anterior pituitary gland will lead to an increase in serum and urinary cortisol levels. An increase, rather than a decrease, in thyroxine level would be expected with increased secretion of thyroid-stimulating hormone (TSH) by the anterior pituitary. Aldosterone and catecholamine levels are not controlled by the anterior pituitary.
The nurse is caring for a patient who is scheduled for a 24-hour urine collection for 17-ketosteroids. Which of the following actions should the nurse implement?
- A. Keep the specimen on ice.
- B. Insert a retention catheter.
- C. Have the patient void and save that specimen to start the collection.
- D. Encourage the patient to drink 2-3 L of fluid during the 24 hours.
Correct Answer: A
Rationale: The specimen must be kept on ice or refrigerated until the collection is finished. Voided or catheterized specimens are acceptable for the test. The initial voided specimen is discarded. There is no fluid intake requirement for the 24-hour collection.
The nurse is caring for a patient who is taking spironolactone. Which of the following parameters should the nurse monitor?
- A. Decreased urinary output
- B. Evidence of fluid overload
- C. Increased serum sodium levels
- D. Elevated serum potassium levels
Correct Answer: D
Rationale: Spironolactone is a diuretic and it blocks aldosterone. Recalling that aldosterone increases the excretion of potassium, a medication that blocks aldosterone will tend to cause hyperkalemia. Aldosterone also promotes the reabsorption of sodium and water in the renal tubules, so spironolactone will tend to cause increased urine output, a decreased or normal serum sodium level, and signs of dehydration.