Nokea
While a patient is receiving beta-1b interferon every other day for multiple sclerosis, which serum laboratory test findings should the nurse monitor to assess for possible bone marrow suppression caused by the medication? (Select all that apply)
- A. Platelet count
- B. White blood cell count (WBC)
- C. Sodium and potassium
- D. Red blood cell count (RBC)
Correct Answer: A
Rationale: Beta-1b interferon can lead to bone marrow suppression, impacting blood cell production. Therefore, monitoring the platelet count, white blood cell count (WBC), and red blood cell count (RBC) is essential. Platelet count is a direct indicator of bone marrow function and can show early signs of bone marrow suppression. While sodium, potassium, and albumin/protein levels are important for overall health assessment, they are not directly associated with bone marrow suppression caused by the medication.
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When gathering subjective data from a client, what intervention should the nurse implement first?
- A. Listen attentively
- B. Establish rapport
- C. List problems
- D. Clarify inferences
Correct Answer: B
Rationale: Establishing rapport is the initial step the nurse should take when gathering subjective data from a client. Building trust and a good relationship with the client creates an environment where the client feels comfortable sharing accurate and honest information. Listening attentively is important but should come after rapport is established to enhance active listening. Listing problems and clarifying inferences are actions that occur later in the assessment process, after the nurse has established a good rapport and obtained a comprehensive understanding of the client's perspective. Therefore, option B is the correct answer.
Which action should the nurse include in the plan of care for a client receiving acyclovir (Zovirax) IV for treatment of herpes zoster (shingles)?
- A. Initiate cardiac telemetry monitoring
- B. Maintain continuous pulse oximetry
- C. Perform capillary glucose measurements
- D. Monitor serum creatinine levels
Correct Answer: D
Rationale: The correct answer is D: Monitor serum creatinine levels. Acyclovir can lead to nephrotoxicity, making it essential to monitor kidney function through serum creatinine levels. While cardiac telemetry monitoring (choice A) and maintaining continuous pulse oximetry (choice B) are important in certain conditions, they are not directly related to acyclovir therapy for herpes zoster. Performing capillary glucose measurements (choice C) is not a priority when administering acyclovir for herpes zoster. Monitoring serum creatinine levels is crucial to detect any potential renal issues early, as the drug's nephrotoxic potential requires close monitoring of kidney function.
A 13-year-old girl, diagnosed with diabetes mellitus Type 1 at the age of 9, is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of the ketoacidosis?
- A. Ate an extra peanut butter sandwich before gym class
- B. Incorrectly drew up and administered too much insulin
- C. Was not hungry, so she skipped eating lunch
- D. Has had a cold and ear infection for the past two days
Correct Answer: B
Rationale: The correct answer is B. Incorrect insulin administration is a common cause of diabetic ketoacidosis. Administering too much insulin can lead to uncontrolled hyperglycemia, where the body starts breaking down fat for energy, resulting in the production of ketones. Choices A, C, and D are less likely to directly cause diabetic ketoacidosis. Eating an extra peanut butter sandwich, skipping lunch, or having a cold and ear infection would not directly lead to the metabolic derangements seen in diabetic ketoacidosis.
A client with complaints of shortness of breath and abdominal pain 1 week after bariatric surgery is admitted for follow-up evaluation. Which assessment finding warrants immediate intervention by the nurse?
- A. Rectal temperature of 101°F
- B. Complaints of left shoulder pain
- C. Blood pressure of 88/50 mmHg
- D. Sustained sinus tachycardia
Correct Answer: C
Rationale: A blood pressure of 88/50 mmHg indicates possible hypovolemia or shock, which requires immediate attention. Hypotension can be a sign of decreased perfusion to vital organs, potentially leading to organ failure. The other options, such as a rectal temperature of 101°F, complaints of left shoulder pain, or sustained sinus tachycardia, while important, do not present the same level of immediate threat to the client's well-being as a critically low blood pressure.
A client with acute renal failure (ARF) is admitted for uncontrolled type 1 diabetes mellitus and hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale. Which intervention is the most important for the nurse to include in this client's plan of care?
- A. Monitor the client's cardiac activity via telemetry.
- B. Maintain venous access with an infusion of normal saline.
- C. Assess glucose levels via finger stick every 4 to 6 hours.
- D. Evaluate hourly urine output for the return of normal renal function.
Correct Answer: A
Rationale: Monitoring cardiac activity is crucial in this scenario because hyperkalemia can lead to serious cardiac dysrhythmias, which can be life-threatening. Regular monitoring of the client's cardiac activity via telemetry allows for early detection of any potential cardiac complications. Maintaining venous access with a normal saline infusion is important for hydration but does not address the immediate risk of cardiac dysrhythmias posed by hyperkalemia. Assessing glucose levels is essential in diabetes management but is not the priority when dealing with hyperkalemia-induced cardiac risks. Evaluating hourly urine output for the return of normal renal function is important in ARF but is not as urgent as monitoring the client's cardiac activity in the context of hyperkalemia.