Nokea
The nurse is preparing to administer tolvaptan to a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following laboratory test results should the nurse review before administering the medication?
- A. hemoglobin (Hgb) and white blood cell (WBC) count
- B. alanine aminotransferase (ALT) and aspartate aminotransferase (AST)
- C. troponin and myoglobin
- D. serum glucose and serum hemoglobin A1C
Correct Answer: B
Rationale: Tolvaptan can cause liver injury, so ALT and AST (liver function tests) should be reviewed before administration. Hemoglobin/WBC, troponin/myoglobin, and glucose/HbA1c are not primary concerns.
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The nurse assesses clients for the risk of developing hyperosmolar hyperglycemic syndrome. Which of the following clients should the nurse consider to be at greatest risk?
- A. 63-year-old with diabetes mellitus (type two) who works outdoors and recently had an increased dosage of metformin.
- B. 55-year-old with diabetes mellitus (type one) who was recently hospitalized for pneumonia and occasionally forgets to take their long-acting insulin.
- C. 15-year-old with diabetes mellitus (type one) who has a hemoglobin A1C of 7.6% [ < 7%] and has gained 4 lbs (1.8 kg) in the past month.
- D. 45-year-old who was recently diagnosed with diabetes mellitus (type two) and was prescribed glipizide in addition to metformin.
Correct Answer: A
Rationale: HHS is common in type 2 diabetes, especially in older adults. Outdoor work risks dehydration, and increased metformin may not control severe hyperglycemia, heightening HHS risk.
The nurse preceptor observes a newly hired nurse care for a client with a myxedema coma. It would require follow up by the nurse preceptor if the newly hired nurse is observed
- A. applying a cooling blanket to the client.
- B. requesting a prescription for hydrocortisone.
- C. removing the water pitcher from the bedside.
- D. placing an oral endotracheal tube at the bedside for potential use.
Correct Answer: A
Rationale: Myxedema coma is a severe hypothyroid state with hypothermia. A cooling blanket worsens this; a warming blanket is needed. Hydrocortisone addresses adrenal insufficiency, removing water prevents dilutional hyponatremia, and an endotracheal tube is prudent for potential respiratory support.
The nurse is caring for a client who presents with hyperglycemia. Which of the following findings are expected?
- A. Blurred vision
- B. Increased urinary output
- C. Cool and clammy skin
- D. Tachycardia
- E. Orthostatic hypotension
Correct Answer: A, B, D
Rationale: Hyperglycemia causes blurred vision (osmotic lens changes), increased urination (osmotic diuresis), and tachycardia (dehydration response). Cool, clammy skin is typical of hypoglycemia, and orthostatic hypotension is less specific.
The nurse is developing a plan of care for a client diagnosed with Addison's disease. Which of the following should the nurse include in the client's plan of care?
- A. Diet high in potassium
- B. Continuous telemetry monitoring
- C. Intravenous hydrocortisone
- D. Fluid restriction
- E. Fall precautions
- F. Indwelling urinary catheter
Correct Answer: C, E
Rationale: Addison's requires hydrocortisone to replace cortisol and fall precautions due to weakness and hypotension. High potassium diets and fluid restriction are harmful; telemetry and catheters are not routine.
The nurse is caring for a client receiving a continuous infusion of regular insulin. The nurse should plan to monitor which clinical data?
- A. Hourly blood glucose
- B. Potassium
- C. BUN and creatinine
- D. Gastric pH
- E. Fasting blood glucose
Correct Answer: A, B
Rationale: Insulin lowers glucose and shifts potassium into cells, risking hypokalemia. Hourly glucose and potassium monitoring are critical to adjust therapy and prevent complications.