Nokea
While gathering data, the nurse notes that the client has been prescribed tolterodine tartrate. The nurse should determine that the client is taking the medication to treat which disorder?
- A. Glaucoma
- B. Pyloric stenosis
- C. Renal insufficiency
- D. Urinary frequency and urgency
Correct Answer: D
Rationale: Tolterodine tartrate is an antispasmodic used to treat overactive bladder and symptoms of urinary frequency, urgency, or urge incontinence. It is contraindicated in urinary retention and uncontrolled narrow-angle glaucoma. It is used with caution in renal function impairment, bladder outflow obstruction, and gastrointestinal obstructive disease such as pyloric stenosis.
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The nurse is caring for a client who is receiving tobramycin sulfate intravenously every 8 hours. Which result should indicate to the nurse that the client is experiencing an adverse effect of the medication?
- A. A total bilirubin of 0.5 mg/dL (8.5 mcmol/L)
- B. An erythrocyte sedimentation rate of 15 mm/hour
- C. A blood urea nitrogen (BUN) of 30 mg/dL (10.8 mmol/L)
- D. A white blood cell count (WBC) of 6000 mm³ (6 × 10â¹/L)
Correct Answer: C
Rationale: Tobramycin sulfate is an aminoglycoside antibiotic. Adverse effects or toxic effects of tobramycin sulfate include nephrotoxicity as evidenced by an increased BUN and serum creatinine; irreversible ototoxicity as evidenced by tinnitus, dizziness, ringing or roaring in the ears, and reduced hearing; and neurotoxicity as evidenced by headaches, dizziness, lethargy, tremors, and visual disturbances. The normal BUN ranges from 10 to 20 mg/dL (3.6 to 7.1 mmol/L), depending on the laboratory. The normal total bilirubin level ranges from 0.3 to 1.0 mg/dL (5.1 to 17 mcmol/L). The normal sedimentation rate for a male is ≤15 mm/hr and for a female is ≤20 mm/hr. A normal WBC count is 5000 to 10,000 mm³ (5 to 10 × 10â¹/L).
The nurse is conducting a health history on a client diagnosed with hyperparathyroidism. Which question asked of the client would elicit information about this condition?
- A. Do you have tremors in your hands?
- B. Are you experiencing pain in your joints?
- C. Have you had problems with diarrhea lately?
- D. Do you notice any swelling in your legs at night?
Correct Answer: B
Rationale: Hyperparathyroidism causes an oversecretion of parathyroid hormone (PTH), which causes excessive osteoblast growth and activity within the bones. When bone reabsorption is increased, calcium is released from the bones into the blood, causing hypercalcemia. The bones suffer demineralization as a result of calcium loss, leading to bone and joint pain and pathological fractures. Options 1 and 3 relate to assessment of hypoparathyroidism. Option 4 is unrelated to hyperparathyroidism.
A client who underwent surgical repair of an abdominal aortic aneurysm is 1 day postoperative. The nurse performs an abdominal assessment and notes the absence of bowel sounds. What action should the nurse take?
- A. Start the client on sips of water.
- B. Remove the nasogastric (NG) tube.
- C. Call the primary health care provider immediately.
- D. Document the finding and continue to assess for bowel sounds.
Correct Answer: D
Rationale: Bowel sounds may be absent for 3 to 4 postoperative days because of bowel manipulation during surgery. The nurse should document the finding and continue to monitor the client. The NG tube should stay in place if present, and the client is kept NPO until after the onset of bowel sounds. Additionally, the nurse does not remove the tube without a prescription to do so. There is no need to call the primary health care provider immediately at this time.
Twelve hours after delivery, the nurse assesses the client for uterine involution. The nurse determines that the uterus is progressing normally toward its prepregnancy state when palpation of the client's fundus is at which level?
- A. At the umbilicus
- B. One finger breadth below the umbilicus
- C. Two finger breadths below the umbilicus
- D. Midway between the umbilicus and the symphysis pubis
Correct Answer: A
Rationale: The term 'involution' is used to describe the rapid reduction in size and the return of the uterus to a normal condition similar to its nonpregnant state. Immediately after the delivery of the placenta, the uterus contracts to the size of a large grapefruit. The fundus is situated in the midline between the symphysis pubis and the umbilicus. Within 6 to 12 hours after birth, the fundus of the uterus rises to the level of the umbilicus. The top of the fundus remains at the level of the umbilicus for about a day and then descends into the pelvis approximately one finger breadth on each succeeding day.
A client has undergone angioplasty of the iliac artery. Which technique should the nurse perform to best detect bleeding from the angioplasty in the region of the iliac artery?
- A. Palpate the pedal pulses.
- B. Measure the abdominal girth.
- C. Assess the client about the level of pain in the area.
- D. Auscultate over the iliac area with a Doppler device.
Correct Answer: B
Rationale: Bleeding after iliac artery angioplasty causes blood to accumulate in the retroperitoneal area. This can most directly be detected by measuring abdominal girth. Palpation and auscultation of pulses determine patency. Assessment of pain is routinely done, and mild regional discomfort is expected.