Nokea
When administering spironolactone (Aldactone) to a client who has had a unilateral adrenalectomy, the nurse should instruct the client about which of the following possible adverse effects of the drug?
- A. Breast tenderness
- B. Increased facial hair
- C. Menstrual irregularities
- D. Hair loss
Correct Answer: C
Rationale: Spironolactone (Aldactone) is a potassium-sparing diuretic and aldosterone antagonist that is commonly used to treat conditions such as hypertension, heart failure, and edema. One of its common side effects is hormonal effects due to its antiandrogenic properties. In women, spironolactone can lead to menstrual irregularities, including amenorrhea (absence of menstrual periods) or breakthrough bleeding. Therefore, in a client who has had a unilateral adrenalectomy (removal of one adrenal gland), which can already disrupt hormonal balance, the nurse should educate the client about the potential for menstrual irregularities when taking spironolactone.
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Alaric was diagnosed with minimal-change nephrotic syndrome; which of the following signs and symptoms are characteristics of the said disorder?
- A. Hypertension, edema, hematuria
- B. Hypertension, edema, proteinuria
- C. Gross hematuria, fever, proteinuria
- D. Poor appetite, edema, proteinuria
Correct Answer: B
Rationale: Minimal-change nephrotic syndrome is a kidney disorder characterized by the presence of proteinuria, which is the excessive loss of protein in the urine. This leads to low levels of protein in the blood, causing edema (swelling) due to fluid accumulation in the tissues. In minimal-change nephrotic syndrome, hypertension (high blood pressure) is not a typical finding. Instead, patients often present with normal blood pressure levels. Additionally, hematuria (presence of blood in the urine) is not a common symptom of this disorder. Therefore, the key signs and symptoms characteristic of minimal-change nephrotic syndrome are edema, proteinuria, and the absence of hypertension.
A client diagnosed with DIC is ordered heparin. What is the reason for this medication?
- A. Prevent clot formation
- B. Increase clot formation
- C. Increased blood flow to target organs
- D. Decrease blood flow to target organs
Correct Answer: A
Rationale: Heparin is a medication commonly used to prevent clot formation in various clinical conditions, including Disseminated Intravascular Coagulation (DIC). DIC is a serious condition characterized by abnormal blood clotting and bleeding throughout the body. Heparin works by inhibiting the formation of new clots and preventing the existing clots from further growing, thus helping to manage and prevent complications associated with DIC. By using heparin, the aim is to help stabilize the patient's clotting process and reduce the risk of severe complications such as organ damage or failure.
The nurse assesses a client shortly after kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?
- A. Serum potassium level of 4.9mEq/L
- B. Temperature of 99.2F (37.3C)
- C. Serum sodium level of 135mEq/L
- D. Urine output of 20mL/hour
Correct Answer: D
Rationale: A low urine output of 20mL/hour shortly after kidney transplant surgery is a critical finding that must be reported to the physician immediately. Adequate urine output is essential to ensure proper kidney function and the body's ability to eliminate waste products and regulate electrolyte levels. A urine output of less than 30mL/hour is considered oliguria, which may indicate decreased kidney function or potential complications such as acute kidney injury. Therefore, prompt evaluation and intervention are necessary to prevent further kidney damage or complications in the client.
A patient is hemorrhaging from multiple trauma sites. The nurse expects that compensatory mechanisms associated with hypovolemia would cause all of the following symptoms except:
- A. Hypertension
- B. Tachycardia
- C. Oliguria
- D. Tachypnea
Correct Answer: A
Rationale: In a patient experiencing hemorrhage from multiple trauma sites leading to hypovolemia, compensatory mechanisms typically include an increase in heart rate (tachycardia), a decrease in urine output (oliguria), and an increase in respiratory rate (tachypnea). These mechanisms are the body's way of trying to maintain vital organ perfusion in the setting of decreased blood volume. However, hypertension is not typically seen in the setting of hypovolemia. In fact, blood pressure tends to decrease as a result of reduced circulating volume.
A preschool child is scheduled for an echocardiogram. Parents ask the nurse whether they can hold the child during the procedure. The nurse should answer with which response?
- A. "You will be able to hold your child during the procedure."
- B. "Your child can be active during the procedure, but can't sit in your lap."
- C. "Your child must lie quietly; sometimes a mild sedative is administered before the procedure."
- D. "The procedure is invasive so your child will be restrained during the echocardiogram."
Correct Answer: A
Rationale: The correct response is that "You will be able to hold your child during the procedure." It is common for parents to be allowed to hold their child during an echocardiogram to provide comfort and reassurance. This can help the child stay calm and cooperative during the procedure. Holding the child can also create a familiar and secure environment, making it easier for the healthcare provider to perform the echocardiogram successfully.