Nokea
Vasopressin (Pitressin) is administered to the client with diabetes insipidus because it:
- A. Decreases blood pressure.
- B. Increases tubular reabsorption of water.
- C. Increases release of insulin from the pancreas.
- D. Decreases glucose production within the liver.
Correct Answer: B
Rationale: Vasopressin increases water reabsorption in the kidneys, reducing urine output in diabetes insipidus.
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The nurse should remind the unlicensed personnel that which of the following is the most important goal in the care of the neutropenic client in isolation?
- A. Listening to the client's feelings of concern.
- B. Completing the client's care in a nonhurried manner.
- C. Performing all of the client's care at one time.
- D. Instructing the client to dispose of tissue after blowing the nose.
Correct Answer: C
Rationale: Performing all care at one time minimizes disruptions and reduces the risk of introducing pathogens to a neutropenic client in isolation. Emotional support, nonhurried care, and tissue disposal are important but secondary to infection prevention.
The nurse should tell the client to do which of the following when teaching the client about taking oral glucocorticoids?
- A. Take your medication with a full glass of water.'
- B. Take your medication on an empty stomach.'
- C. Take your medication at bedtime to increase absorption.'
- D. Take your medication with meals or with an antacid.'
Correct Answer: D
Rationale: Taking glucocorticoids with meals or an antacid reduces gastrointestinal irritation, a common side effect.
A client with cancer verbalizes that he is afraid he won't be able to cope with all the issues that will arise. The nurse can best support the coping behaviors of a client with cancer by:
- A. Helping the client identify available resources.
- B. Encouraging compliance with treatment regimens.
- C. Relieving the client of decision making as much as possible.
- D. Assisting the client to prepare for adverse treatment effects.
Correct Answer: A
Rationale: Identifying available resources empowers the client to manage challenges, enhancing their coping ability and reducing fear.
The client with a major burn injury receives total parenteral nutrition (TPN). The expected outcome is to:
- A. Correct water and electrolyte imbalances.
- B. Allow the gastrointestinal tract to rest.
- C. Provide supplemental vitamins and minerals.
- D. Ensure adequate caloric and protein intake.
Correct Answer: D
Rationale: Major burn injuries significantly increase metabolic demands, requiring high caloric and protein intake to support healing and tissue repair. TPN is primarily used to meet these nutritional needs when oral or enteral feeding is not feasible.
For a client with rib fractures and a pneumothorax, the physician prescribes morphine sulfate, 1 to 2 mg/hour, given I.V. as needed for pain. The nursing care goal is to provide adequate pain control so that the client can breathe effectively. Which of the following outcomes would indicate successful achievement of this goal?
- A. Pain rating of 0 on a scale of 0 to 10 by the client.
- B. Respiratory rate of 26 breaths/minute.
- C. PaO2 of 70 mm Hg.
- D. None of the above
Correct Answer: A
Rationale: A pain rating of 0 indicates adequate pain control, enabling effective breathing. A respiratory rate of 26 is elevated, and a PaO2 of 70 mm Hg suggests mild hypoxemia, neither confirming pain control.