Nokea
The nurse should caution the client with diabetes mellitus who is taking a sulfonylurea that alcoholic beverages should be avoided while taking these drugs because they can cause which of the following?
- A. Hypokalemia.
- B. Hyperkalemia.
- C. Hypocalcemia.
- D. Disulfiram (Antabuse)-like symptoms.
Correct Answer: D
Rationale: Sulfonylureas combined with alcohol can cause disulfiram-like symptoms, such as flushing, nausea, and palpitations.
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The client has had a cataract removed. The nurse's discharge instructions should include which of the following?
- A. Keep the head aligned straight.
- B. Utilize bright lights in the home.
- C. Use an eye shield at night.
- D. Change the eye patch as needed.
Correct Answer: C
Rationale: Using an eye shield at night prevents rubbing the eye. The head should be turned to the side to scan the entire visual field to compensate for impaired peripheral vision. Eye medications may initially cause sensitivity to bright light. The surgeon changes the eye patch on the second postoperative day.
The nurse is caring for a client who has been prescribed infusions of amphotericin b. Which laboratory data is necessary for the nurse to monitor during treatment?
- A. Triglycerides
- B. Hemoglobin A1C
- C. Potassium
- D. High-density lipoprotein (HDL)
Correct Answer: C
Rationale: Amphotericin B can cause electrolyte imbalances, particularly hypokalemia, so monitoring potassium levels (Choice C) is essential. Choices A (triglycerides), B (hemoglobin A1C), and D (HDL) are not directly affected by amphotericin B and are not routinely monitored during treatment.
Following a laryngectomy, the nurse notices that the client has saliva collecting beneath the skin flaps. This finding is indicative of which of the following?
- A. Skin necrosis.
- B. Carotid artery rupture.
- C. Stomal Stenosis.
- D. Development of a fistula.
Correct Answer: D
Rationale: Saliva collecting beneath skin flaps post-laryngectomy indicates a fistula, where saliva leaks from the pharynx or esophagus into surrounding tissues, requiring immediate attention.
A client with acute renal failure is at risk for:
- A. Infection.
- B. Hypoglycemia.
- C. Hypernatremia.
- D. Bone fractures.
Correct Answer: A
Rationale: Infection risk is high due to impaired immune response and dialysis access.
A client has a tibial fracture that required casting. Approximately 5 hours later, the client has increasing pain distal to the left tibial fracture despite the morphine injection administered 30 minutes previously. Which of the following should be the nurse's next assessment?
- A. Presence of a distal pulse.
- B. Pain with a pain rating scale.
- C. Skin temperature.
- D. Potential for drug tolerance.
Correct Answer: A
Rationale: Increasing pain despite analgesia suggests compartment syndrome; checking the distal pulse assesses for vascular compromise.