Nokea
When administering intravenous electrolyte solution, which of the following precautions should the nurse take?
- A. Infuse hypertonic solutions cautiously.
- B. Mix no more than 60 mEq of potassium per liter of fluid.
- C. Prevent infiltration of calcium, which causes tissue necrosis and sloughing.
- D. Monitor the client's digitalis dosage for potential adjustments due to IV calcium administration.
Correct Answer: C
Rationale: When administering intravenous electrolyte solutions, it is crucial to prevent infiltration of calcium to avoid tissue necrosis and sloughing. Hypertonic solutions should be infused cautiously (Choice A) to prevent adverse effects. The correct amount of potassium to be mixed in a liter of fluid is no more than 60 mEq, making Choice B incorrect. While monitoring the client's digitalis dosage for potential adjustments due to IV calcium administration is important, the statement suggesting an increased dosage is incorrect as IV calcium diminishes digitalis's action, making Choice D incorrect.
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A client had a C5 spinal cord contusion that resulted in quadriplegia. Two days after the injury occurred, the nurse sees his mother crying in the waiting room. The mother asks the nurse whether her son will ever play football again. Which of the following is the best initial response?
- A. "Given time and motivation, your son may regain some function, but I will seek more information from the physician."?
- B. Maintain a calm demeanor and speech pattern while addressing the mother's concerns.
- C. "I'm not sure, but I'll call the physician to discuss this with you promptly."?
- D. "It's not beneficial for your son if you get upset."?
Correct Answer: C
Rationale: The best initial response in this situation is to acknowledge the mother's concern, express uncertainty, and offer to obtain more information from the physician. By saying, "I'm not sure, but I'll call the physician to discuss this with you promptly,"? the nurse demonstrates empathy, honesty, and a commitment to providing accurate information. Offering vague reassurance (Choice A) may raise false hopes as outcomes for spinal cord injuries are unpredictable. While maintaining a calm demeanor (Choice B) is important, it does not directly address the mother's immediate need for information. Discouraging the mother from feeling upset (Choice D) is dismissive of her emotions and does not address her question, which is seeking information about her son's prognosis.
The chemotherapeutic agent 5-fluorouracil (5-FU) is ordered for a client as an adjunct measure to surgery. Which statement about chemotherapy is true?
- A. It is a local treatment affecting only tumor cells.
- B. It is a systemic treatment affecting both tumor and normal cells.
- C. It has not yet been proven an effective treatment for cancer.
- D. It is often the drug of choice because it causes few, if any, side effects.
Correct Answer: B
Rationale: The correct answer is that chemotherapy is a systemic treatment affecting both tumor and normal cells. 5-FU, as an antimetabolic drug, inhibits DNA synthesis and interferes with cell replication systemically. It affects all rapidly growing cells, including malignant and normal ones. This drug is used as adjuvant therapy for various cancers. Choice A is incorrect because chemotherapy affects both tumor and normal cells, not just tumor cells. Choice C is incorrect as chemotherapy has been proven effective in treating cancer. Choice D is incorrect because chemotherapy often causes side effects like bone marrow depression, anorexia, stomatitis, nausea, and vomiting.
Levothyroxine (Synthroid) is the drug of choice for thyroid replacement therapy in clients with hypothyroidism because:
- A. it is chemically stable, nonallergenic, and can be administered orally once a day.
- B. it is available in a wide range of concentrations to meet individual client requirements.
- C. it is a prodrug of T3.
- D. it has a long half-life.
Correct Answer: A
Rationale: Levothyroxine (Synthroid) is the preferred medication for hypothyroidism due to its chemical stability, nonallergenic properties, and convenient once-daily oral administration. It is safe and effective with minimal side effects when appropriately dosed. Choice B is incorrect because while Levothyroxine is available in various concentrations, it is not the reason it is the drug of choice; the primary reason is its stability and nonallergenic nature. Choice C is wrong as Levothyroxine (T4) is not a prodrug of T3; it is converted to T3 in the body. Option D is inaccurate because Levothyroxine has a long half-life (around 7 days), enabling once-daily dosing, as opposed to a short half-life.
The client with peripheral vascular disease is reviewing self-care measures. Which of the following statements indicates proper self-care measures?
- A. "I like to soak my feet in the hot tub every day."?
- B. "I walk to the mailbox in my bare feet."?
- C. "I stopped smoking and only use chewing tobacco."?
- D. "I have my wife examine the soles of my feet each day."?
Correct Answer: D
Rationale: The correct answer is, "I have my wife examine the soles of my feet each day."? Clients with peripheral vascular disease should examine their feet daily for any signs of redness, dryness, or cuts. If the client is unable to do this themselves due to decreased sensation in their feet, a caregiver or family member should assist. Soaking feet in a hot tub should be avoided as the client may not be able to sense if the water is too hot, potentially causing burns. Walking barefoot can lead to injuries, so wearing shoes or slippers is recommended to minimize trauma. While quitting smoking is a positive step, using chewing tobacco can still constrict blood vessels, adversely affecting circulation in the extremities.
The nurse is checking laboratory values on a patient who has crackling rales in the lower lobes, 2+ pitting edema, and dyspnea with minimal exertion. Which of the following laboratory values does the nurse expect to be abnormal?
- A. Potassium.
- B. B-type natriuretic peptide (BNP).
- C. C-reactive protein (CRP).
- D. Platelets.
Correct Answer: B
Rationale: The client's symptoms suggest heart failure. BNP is a neurohormone released from the ventricles due to increased pressure and stretch, as seen in heart failure. A BNP level greater than 51 pg/mL is often associated with mild heart failure, with higher levels indicating more severe heart failure. Potassium levels are not typically affected by heart failure. CRP is an inflammation indicator used to predict coronary artery disease risk, not directly related to heart failure in this case. The client's symptoms do not suggest bleeding or clotting abnormalities associated with platelet count issues, making platelets an unlikely abnormal value.