Nokea
The physician has ordered a paracentesis for a client with severe abdominal ascites. Before the procedure, the nurse should:
- A. Provide the client with a urinal
- B. Prep the area by shaving the abdomen
- C. Encourage the client to drink extra fluids
- D. Request an ultrasound of the abdomen
Correct Answer: A
Rationale: Providing a urinal ensures the bladder is empty, reducing the risk of bladder puncture during paracentesis, a priority before the procedure.
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The nurse notes hyperventilation in a client with a thermal injury. She recognizes that this may be a reaction to which of the following medications if applied in large amounts?
- A. Neosporin sulfate
- B. Mafenide acetate
- C. Silver sulfadiazine
- D. Povidone-iodine
Correct Answer: B
Rationale: Mafenide acetate can cause metabolic acidosis, leading to compensatory hyperventilation. The other medications listed do not typically cause this reaction.
A client has recently been diagnosed with primary open-angle glaucoma. The nurse should tell the client to avoid taking:
- A. Aleve (naprosyn)
- B. Benadryl (diphenhydramine)
- C. Tylenol (acetaminophen)
- D. Robitussin (guaifenesin)
Correct Answer: B
Rationale: Benadryl, an antihistamine, can increase intraocular pressure, worsening primary open-angle glaucoma, so it should be avoided.
Stat serum electrolytes ordered for a client in acute renal failure revealed a serum potassium level of 6.4. The physician is immediately notified and orders 50 mL of dextrose and 10 U of regular insulin IV push. The nurse administering these drugs knows the rationale for this therapy is to:
- A. Remove the potassium from the body by renin exchange
- B. Protect the myocardium from the effects of hypokalemia
- C. Promote rapid protein catabolism
- D. Drive potassium from the serum back into the cells
Correct Answer: D
Rationale: Sodium polystyrene sulfonate (Kayexalate), a cation exchange resin, exchanges sodium ions for potassium ions in the large intestine reducing the serum potassium. Calcium is administered to protect the myocardium from the adverse effects of hyperkalemia. Serum levels reflect hyperkalemia. Rapid catabolism releases potassium from the body tissue into the bloodstream. Infection and hyperthermia increase the process of catabolism. The administration of dextrose and regular insulin IV forces potassium back into the cells decreasing the potassium in the serum.
A female client is concerned that she is in a 'high-risk' group for the development of acquired immunodeficiency syndrome (AIDS). She wants to know about the advisability of donating blood. Which of the following responses is correct?
- A. Individuals who donate blood are at risk of getting the AIDS virus. You should not donate.'
- B. It's OK for you to donate because the blood bank has a test that is 100% effective.'
- C. You should not donate since it takes time to develop antibodies to the AIDS virus. If you donate blood before you develop the antibody, you could pass it on in the blood.'
- D. It is not a good idea for you to donate. If you have AIDS, the information is made public and could destroy your personal life.'
Correct Answer: C
Rationale: The AIDS virus cannot be transmitted to the donor through the blood donation procedure. The test for the AIDS virus is not absolutely foolproof; therefore, it is not wise for a person with known risk factors to donate blood. It takes time for antibodies to the AIDS virus to develop. An infected individual could donate contaminated blood without it testing positive for the virus. For reasons of confidentiality, information about individuals infected with AIDS is not made public.
A client is admitted to the labor and delivery unit in active labor. The physician performs an amniotomy. Which observation would the nurse expect to make immediately after the amniotomy?
- A. Fetal heart tones 160 bpm
- B. Moderate uterine contractions
- C. A large amount of straw-colored fluid
- D. Thick green amniotic fluid
Correct Answer: C
Rationale: After an amniotomy the nurse expects to observe a large amount of clear or straw-colored amniotic fluid indicating normal amniotic fluid. Fetal heart tones of 160 bpm are normal but not specific to amniotomy contractions are unrelated and green fluid suggests meconium which is abnormal.