Nokea
Which of the following should be included in the nurse's preadministration assessment of a client about to receive somatropin (Nutropin)? Select all that apply.
- A. Height
- B. Weight
- C. Blood pressure
- D. Pulse
- E. Respiratory rate
Correct Answer: A,B,C,D,E
Rationale: Blood pressure, pulse, respiratory rate, temperature, height, and weight should be included in the nurse's preadministration assessment of a client about to receive somatropin (Nutropin).
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A nurse completing discharge counseling should advise a client taking vasopressin (Pressyn) to notify the physician if which of the following occur? Select all that apply.
- A. Changes in urine output
- B. Abdominal cramps
- C. Skin blanching
- D. Diarrhea
- E. Cough
Correct Answer: A,B,C
Rationale: A nurse completing discharge counseling should advise a client taking vasopressin (Pressyn) to notify the physician if any of the following occur: a significant increase or decrease in urine output, abdominal cramps, skin blanching, nausea, confusion, headache, drowsiness, or signs of inflammation or infection at the injection sites.
A client with diabetes insipidus has been prescribed vasopressin. The client's ambulatory status is limited. Which of the following would be most important for this client?
- A. Measuring the amount of fluid loss every 24 hours
- B. Refilling the water container at frequent intervals
- C. Giving four glasses of water immediately after the client takes the drug
- D. Examining the client's abdomen every 15 to 30 minutes
Correct Answer: B
Rationale: Clients with diabetes insipidus are continually thirsty, and in this case, the client also has limited ambulatory activities. Therefore, the nurse should be careful to refill the water container at frequent intervals to ensure the availability of enough drinking water at hand for the client. The nurse need not be careful to measure the amount of fluid loss every 24 hours, give four glasses of water immediately after the client takes the drug, or examine the client's abdomen every 15 to 30 minutes. The nurse instructs the client to measure the amount of urine excreted at each voiding and then total the amount for each 24-hour period. The nurse should instruct the client to drink one or two glasses of water immediately before taking the drug. The nurse need not auscultate the abdomen every 15 to 30 minutes in a client with diabetes insipidus. The nurse auscultates the abdomen every 15 to 30 minutes in a client with abdominal distention.
The nurse should educate a client receiving adrenocorticotropic hormone (ACTH) to report which of the following to the health care provider? Select all that apply.
- A. Malaise
- B. Sores that don't heal
- C. Otic irritation
- D. Fever
- E. Diarrhea
Correct Answer: A,B,D
Rationale: The nurse instructs a client receiving adrenocorticotropic hormone (ACTH) to report any of the following adverse reactions to the physician: sore throat, cough, fever, malaise, sores that don't heal, or redness or irritation of the eyes.
A client has been prescribed glucocorticoids for the treatment of congenital adrenal hyperplasia. Which of the following assessments should the nurse perform for the client?
- A. Take and record vital signs every 4 to 8 hours.
- B. Test the serum electrolyte levels.
- C. Auscultate the abdomen and record the findings.
- D. Observe for signs of blanching of the skin.
Correct Answer: A
Rationale: When glucocorticoids are administered to the client, the nurse should take and record vital signs every 4 to 8 hours. The nurse need not perform assessments related to serum electrolyte levels, abdominal auscultation, or skin blanching. These are appropriate for a client receiving vasopressin therapy.
A nurse is educating a client and his family about vasopressin (DDAVP) for the treatment of diabetes insipidus. In addition to administration instructions, which of the following should the nurse discuss with the client and family? Select all that apply.
- A. Wearing a medical alert bracelet
- B. Monitoring the daily intake of fluids
- C. Avoiding sun exposure while using the drug
- D. Carrying extra doses with the client at all times
- E. Carrying liquids with the client at all times
Correct Answer: A,B,D,E
Rationale: In addition to administration instructions, the nurse should include the following: wear a medical alert bracelet, monitor the daily intake and output of fluids, avoid the use of alcohol, and carry extra doses and liquids with the client at all times.