Nokea
An adult male developed diabetes insipidus following a craniotomy.
Which of the following statements, if made by the client, would indicate that further teaching is needed?
- A. I should keep a daily record of my fluid intake and how much I go to the bathroom.
- B. I should call my doctor if I seem thirsty a lot and my urine specific gravity is less than 1.005.
- C. I should weigh myself every day and drink less fluid if I gain more than 5 lb over a week.
- D. I will need to take the nose spray medication for the rest of my life.
Correct Answer: C
Rationale: Strategy: 'Further teaching' indicates an incorrect response. (1) disorder or water metabolism caused by deficiency of ADH (antidiuretic hormone) by pituitary gland, symptoms are increased urinary output (4-30 L/24 h), dilute urine with specific gravity less than 1.005 (2) normal specific gravity 1.003-1.030 (3) correct-weight gain should be reported to physician, may need medication adjusted (4) desmopressin (DDAVP) nasally or SQ required for remainder of life
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A client receiving amphotericin B (Fungizone) 1 mg in 250 cc of 5% dextrose in water IV over a 2-hour period.
The nurse should be MOST concerned if which of the following was observed?
- A. BUN 7.2 mg/dL, creatinine 0.5 mg/dL.
- B. BP 90/60, complaints of fever and chills.
- C. Complaints of burning on urination, thirst, and dizziness.
- D. AST (SGOT) 12 U/L, ALT (SGPT) 14 U/L, total bilirubin 0.2 mg/dL.
Correct Answer: B
Rationale: Strategy: 'MOST concerned' indicates an untoward effect of the medication. (1) normal results, causes renal toxicity, BUN and creatine would be elevated, normal BUN 7-18 mg/dL, normal creatine 0.6-1.2 mg/dL (2) correct-monitor vital signs every 30 min (3) not side effect of medication (4) normal AST (formerly SGOT) 8-20 U/L, normal ALT (formerly SGPT) 8-20 U/L, normal bilirubin 0.1-1.0 mg/dL, may cause elevation, check liver function studies weekly, notify physician if elevated
A client develops severe, crushing chest pain radiating to the left shoulder and arm.
Which of the following PRN medications should the nurse administer?
- A. Diazepam (Valium) PO.
- B. Meperidine (Demerol) IM.
- C. Morphine sulfate IV.
- D. Nitroglycerine (Nitrostat) SL.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) not an appropriate medication in this situation; antianxiety medication (2) Demerol is less commonly used because it may induce vomiting and initiate a vagal response (3) correct-morphine sulfate is given to reduce pain, anxiety, and cardiac workload; reduces the preload and afterload pressures (4) although a client at home may have taken NTG SL, the nurse would administer it IV to reduce pain and decrease overload
The nurse is caring for a client who is receiving chemotherapy and has a platelet count of 50,000/mm^3. Which of the following actions is the PRIORITY?
- A. Administer pain medication as needed.
- B. Monitor for signs of bleeding.
- C. Encourage the client to ambulate.
- D. Provide a soft diet.
Correct Answer: B
Rationale: A platelet count of 50,000/mm^3 indicates thrombocytopenia, increasing bleeding risk. Monitoring for bleeding (e.g., petechiae, hematomas) is the priority to detect complications early. Options A, C, and D are secondary: pain management, ambulation, and diet are less urgent.
The nurse is caring for a client with a history of alcoholism.
- A. Which laboratory finding is most concerning for a client with chronic alcoholism?
- B. Serum potassium of 3.2 mEq/L.
- C. Blood urea nitrogen of 18 mg/dL.
- D. Hemoglobin of 13.5 g/dL.
- E. Aspartate aminotransferase (AST) of 150 U/L.
Correct Answer: A
Rationale: A serum potassium of 3.2 mEq/L indicates hypokalemia, a life-threatening complication in chronic alcoholism due to poor nutrition and diuretic effects of alcohol, risking arrhythmias. Elevated AST reflects liver damage, but hypokalemia is more immediately dangerous.
A client has a three-way Foley catheter following a transurethral resection.
The nurse would anticipate infusing irrigating solution rapidly when
- A. the urinary output is increased.
- B. bright-red drainage or clots are present.
- C. dark-brown drainage is present.
- D. the client complains of pain.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) not a reason to infuse irrigating solution rapidly (2) correct-three-way Foley catheter should be irrigated rapidly when bright-red drainage or clots are present; irrigation rate should be decreased to about 40 gtts/min when the drainage clears (3) not indication to infuse irrigating solution rapidly (4) not indication to infuse irrigating solution rapidly