Nokea
The patient is being discharged on furosemide (Lasix). The nurse evaluates the patient as understanding her medication teaching if she states that she will have which of the ff. laboratory tests monitored as ordered?
- A. "I will have my urine sodium checked."
- B. "I will have my prothrombin time checked."
- C. "I will have my calcium level checked."
- D. "I will have my potassium level checked."
Correct Answer: D
Rationale: Furosemide (Lasix) is a loop diuretic that works by increasing the excretion of water and electrolytes such as sodium, chloride, and potassium in the urine. One of the most common side effects of furosemide is hypokalemia, or low potassium levels. Monitoring potassium levels is crucial while taking furosemide to prevent complications such as muscle weakness, cardiac arrhythmias, and other electrolyte imbalances. Therefore, the patient should have her potassium level checked as ordered to ensure her safety and effectiveness of treatment.
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Following a unilateral adrenalectomy, the nurse would assess for hyperkalemia shown by which of the following?
- A. Muscle weakness
- B. Diaphoresis
- C. Tremors
- D. Constipation
Correct Answer: A
Rationale: Following a unilateral adrenalectomy, there is a risk of developing hyperkalemia due to the altered balance of electrolytes. Hyperkalemia is characterized by high levels of potassium in the blood, which can lead to various symptoms. One of the key manifestations of hyperkalemia is muscle weakness. This occurs because high potassium levels can disrupt the normal function of skeletal muscles, leading to weakness and potentially affecting motor function. Therefore, the nurse would assess for muscle weakness as a sign of hyperkalemia in a patient following a unilateral adrenalectomy. Options B, C, and D are not typically associated with hyperkalemia.
A nurse is teaching a class on breastfeeding to expectant parents. Which are contraindications for breastfeeding? (Select all that apply.)
- A. Human immunodeficiency virus (HIV) in mother
- B. Mastitis
- C. Inverted nipples
- D. Maternal cancer therapy
Correct Answer: A
Rationale: Human immunodeficiency virus (HIV) in mother: Breastfeeding is contraindicated in mothers with HIV because the virus can be transmitted to the infant through breast milk.
An infant has been pronounced dead from sudden infant death syndrome (SIDS) in the emergency department. Which is an appropriate question to ask the parents?
- A. "Did you hear the infant cry out?"
- B. "Why didn't you check on the infant earlier?"
- C. "What time did you find the infant?"
- D. "Was the head buried in a blanket?"
Correct Answer: C
Rationale: This is an appropriate question to ask the parents because determining the time the infant was found is important for investigating the circumstances surrounding the sudden infant death syndrome (SIDS) event. Understanding the timeline can help healthcare providers gather valuable information to determine the cause of death and evaluate any potential contributing factors. This question also allows the healthcare team to better understand the sequence of events leading up to the tragic outcome and offer support to the grieving parents. Asking about the time the infant was found is non-accusatory and focuses on gathering relevant details for the medical evaluation.
The physician orders cystoscopy and random biopsies of the bladder for a client who reports painless hematuria. Test results reveal carcinoma in situ in several bladder regions. To treat bladder cancer, the client will have a series of intravesical instillations of bacillus Calmette-Guerin (BCG), administered 1 week apart. When teaching the client about BCG, the nurse should mention that this drug commonly causes:
- A. Renal calculi
- B. Delayed ejaculation
- C. Hematuria
- D. Impotence
Correct Answer: C
Rationale: Bacillus Calmette-Guerin (BCG) is a form of immunotherapy used to treat bladder cancer by stimulating the immune system to attack cancer cells in the bladder. One of the common side effects of BCG therapy is hematuria, which is the presence of blood in the urine. This can be expected due to the irritation caused by the BCG instillations in the bladder lining. Hematuria is usually mild to moderate and can resolve on its own without specific treatment.
A child is being discharged from an ambulatory care center after an inguinal hernia repair. Which discharge interventions should the nurse implement? (Select all that apply.)
- A. Discuss dietary restrictions.
- B. Hold any analgesic medications until the child is home.
- C. Send a pain scale home with the family.
- D. Suggest the parents fill the prescriptions on the way home.
Correct Answer: A
Rationale: Discuss dietary restrictions: It is important to provide the family with information regarding any dietary restrictions that the child may have post-surgery to ensure proper healing and comfort.