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The nurse receives shift report for five clients, and all are taking lithium. Place the clients in the order of priority.
- A. The client who has a dry mouth, headache, and thirst
- B. The client who has a fever, rash, and the start of hives
- C. The client who has blurred vision, ataxia, and tinnitus
- D. The client who has mild hand tremors, nausea, and vomiting
- E. The client who has had increasing confusion, nystagmus, and just had a seizure
Correct Answer: E,C,B,D,A
Rationale: Clients with severe lithium toxicity (E), signs of toxicity (C), allergic reactions (B), side effects needing evaluation (D), and manageable side effects (A) are prioritized in that order.
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A client with stress incontinence should be advised:
- A. to purchase absorbent undergarments.
- B. that Kegel exercises might help.
- C. that effective surgical treatments are nonexistent.
- D. that behavioral therapy is ineffective.
Correct Answer: B
Rationale: Kegel exercises, tightening and releasing the pelvic floor muscles, might improve stress incontinence. Choice A is not an appropriate treatment for stress incontinence. Several effective surgical treatments exist. Lifestyle and dietary modifications can also be helpful.
The nurse is assessing the client who has begun therapy with duloxetine. Which assessment parameter should be the nurse's priority?
- A. Relief of neuropathic pain
- B. Increase in anxiety or irritability
- C. Liver function test (LFT) results
- D. Experiencing suicidal ideations
Correct Answer: D
Rationale: Duloxetine (Cymbalta) is a serotonin norepinephrine reuptake inhibitor (SSNRI) used in the treatment of major depression. Suicidal ideation is the most acute threat to life and should be assessed, especially when initiating duloxetine.
The nurse is evaluating the effectiveness of lispro and glargine insulins being administered to the 2-year-old with type 1 DM. Which findings on the serum laboratory report indicate that treatment is effective?
- A. Blood glucose
- B. Hgb A1c
- C. Creatinine
- D. WBCs
Correct Answer: A, B
Rationale: The treatment goal for children with type 1 DM is blood glucose levels within the normal range (60-105 mg/dL for a 2-year-old). Hgb A1c levels are indicative of the average blood glucose levels over the past 2 to 3 months; normal A1c is 3.9% to 7.7%. Although the other laboratory values are normal, these do not indicate the effectiveness of insulin therapy.
The nurse is initiating an IV infusion of lactated Ringer's (LR) for the client in shock. What is the purpose of LR for this client?
- A. Increase fluid volume and urinary output
- B. Draw water from the cells into the blood vessels
- C. Provide dextrose and nutrients to prevent cellular death
- D. Replace potassium and magnesium for cardiac stabilization
Correct Answer: A
Rationale: A: LR is an isotonic crystalloid solution containing multiple electrolytes in approximately the same concentration as plasma. It enters the cells from the blood, provides fluids, and increases urinary output. B: A hypertonic solution draws fluid from the cells into the vascular compartment; LR is isotonic. C: LR alone does not contain dextrose. Formulations with dextrose are available. D: Magnesium is not a component of LR.
The nurse is assessing the laboratory test results for the male client receiving testosterone replacement therapy for treatment of hypogonadism. Which laboratory test result is most important for the nurse to review?
- A. Fasting lipid profile
- B. Partial thromboplastin time
- C. Urinalysis
- D. Serum potassium
Correct Answer: A
Rationale: A: The most important test is the fasting lipid profile because testosterone can lower plasma levels of HDLs and elevate plasma levels of LDLs, increasing the risk of atherosclerosis. B: Testosterone has little effect on PTT. C: Testosterone has little effect on urine. D: Testosterone has little effect on serum potassium.