Nokea
The nurse is preparing to discharge the client following a unilateral adrenalectomy to treat hyperaldosteronism caused by an adenoma. Which instruction should be included in this client's discharge teaching?
- A. Avoid foods high in potassium
- B. Self-monitor blood pressure daily
- C. Stop drugs taken before adrenalectomy
- D. Carry epinephrine for emergency use
Correct Answer: B
Rationale: Self-monitoring BP is necessary as hypertension may persist in 20% of clients post-adrenalectomy.
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The client diagnosed with type 2 diabetes is admitted to the intensive care unit (ICU) with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) coma. Which assessment data should the nurse expect the client to exhibit?
- A. Kussmaul's respirations.
- B. Diarrhea and epigastric pain.
- C. Dry mucous membranes.
- D. Ketone breath odor.
Correct Answer: C
Rationale: HHNS causes severe dehydration, leading to dry mucous membranes. Kussmaul’s respirations and ketone odor are DKA-specific, and diarrhea/pain are less common.
Antibiotics are ordered for a client who has had a transsphenoidal hypophysectomy. He asks why he is receiving an antibiotic when he does not have an infection. The primary reason for administering antibiotics to this client is based on which information?
- A. Antibiotics will help to prevent respiratory complications following surgery.
- B. Meningitis is a complication following transsphenoidal hypophysectomy.
- C. Fluid retention can cause dangerously high cerebro spinal fluid pressure.
- D. Hormone replacement is essential after hypophysectomy.
Correct Answer: B
Rationale: The transsphenoidal approach through the mouth increases the risk of meningitis due to oral bacteria, necessitating prophylactic antibiotics.
The nurse caring for a client diagnosed with cancer of the pancreas writes the problem of 'altered nutrition: less than body requirements.' Which collaborative intervention should the nurse include in the plan of care?
- A. Continuous feedings via (PEG) tube.
- B. Have the family bring in foods from home.
- C. Assess for food preferences.
- D. Refer to the dietitian.
Correct Answer: D
Rationale: Referring to a dietitian ensures specialized nutritional planning for pancreatic cancer, addressing malabsorption and weight loss. PEG feedings, family foods, and preferences are secondary.
The client diagnosed with Cushing's disease has developed 1++ peripheral edema. The client has received intravenous fluids at 100 mL/hr via IV pump for the past 79 hours. The client received intravenous piggyback (IVPB) medication in 50 mL of fluid every six (6) hours for 15 doses. How many mL of fluid did the client receive?
Correct Answer: 8650 mL
Rationale: Continuous IV: 100 mL/hr × 79 hr = 7900 mL. IVPB: 50 mL × 15 doses = 750 mL. Total = 7900 + 750 = 8650 mL.
The nurse is preparing to administer the following medications. Which medication should the nurse question administering?
- A. The thyroid hormone to the client who does not have a T3, T4 level.
- B. The regular insulin to the client with a blood glucose level of 210 mg/dL.
- C. The loop diuretic to the client with a potassium level of 3.3 mEq/L.
- D. The cardiac glycoside to the client who has a digoxin level of 1.4 mg/dL.
Correct Answer: A
Rationale: Administering thyroid hormone without T3/T4 levels risks overtreatment, as levels confirm hypothyroidism. Insulin, diuretics, and digoxin are appropriate based on data.