Nokea
While preparing to administer an intravenous (IV) medication, the nurse notes that the medication is incompatible with the IV solution. Which intervention should the nurse implement to assure the client's safety?
- A. Ask the provider to prescribe a compatible IV solution.
- B. Start a new IV catheter for the incompatible medication.
- C. Collaborate with the provider for a new administration route.
- D. Flush tubing before and after administering the medication with normal saline.
Correct Answer: D
Rationale: When giving a medication intravenously, if the medication is incompatible with the IV solution, the tubing is flushed before and after the medication with infusions of normal saline to prevent in-line precipitation of the incompatible agents. Starting a new IV, changing the solution, or changing the administration route is unnecessary because a simpler, less risky, viable option exists.
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The nurse is caring for a client scheduled for a bilateral adrenalectomy for treatment of an adrenal tumor. What information should the nurse give the client about the postsurgical needs?
- A. You will need to undergo chemotherapy after surgery.
- B. You will need to wear an abdominal binder after surgery.
- C. You will not need any special long-term treatment after surgery.
- D. You will need to take daily hormone replacements beginning after the surgery.
Correct Answer: D
Rationale: The major cause of primary hyperaldosteronism is an aldosterone-secreting tumor called an aldosteronoma. Surgery is the treatment of choice. Clients undergoing a bilateral adrenalectomy require permanent replacement of adrenal hormones. Options 1, 2, and 3 are inaccurate statements regarding this surgery.
The nurse creates a postoperative plan of care for a client scheduled for a hypophysectomy. Which interventions should be included in the plan of care? Select all that apply.
- A. Obtain daily weights.
- B. Monitor intake and output.
- C. Elevate the head of the bed.
- D. Use a soft toothbrush for mouth care.
- E. Encourage coughing and deep breathing.
Correct Answer: A,B,C
Rationale: A hypophysectomy is done to remove a pituitary tumor. Because temporary diabetes insipidus or syndrome of inappropriate antidiuretic hormone can develop after this surgery, obtaining daily weights and monitoring intake and output are important interventions. The head of the bed is elevated to assist in preventing increased intracranial pressure. Tooth-brushing, sneezing, coughing, nose blowing, and bending are activities that should be avoided postoperatively in the client who underwent a hypophysectomy because of the risk of increasing intracranial pressure. These activities interfere with the healing of the incision and can disrupt the graft.
The nurse is administering magnesium sulfate to a client experiencing severe preeclampsia. What intervention should the nurse implement during the administration of magnesium sulfate for this client?
- A. Schedule a daily ultrasound to assess fetal movement.
- B. Schedule a nonstress test every 4 hours to assess fetal well-being.
- C. Assess the client's temperature every 2 hours because the client is at high risk for infection.
- D. Assess for signs and symptoms of labor since the client's level of consciousness may be altered.
Correct Answer: D
Rationale: Magnesium sulfate is a central nervous system depressant and anticonvulsant. Because of the sedative effect of the magnesium sulfate, the client may not perceive labor. Daily ultrasounds are not necessary for this client. A nonstress test may be done, but not every 4 hours. This client is not at high risk for infection.
The nurse monitoring a preterm newborn infant for manifestations of respiratory distress syndrome (RDS) should assess the infant for which manifestations? Select all that apply.
- A. Cyanosis
- B. Tachypnea
- C. Retractions
- D. Nasal flaring
- E. Acrocyanosis
- F. Grunting respirations
Correct Answer: A,B,C,D,F
Rationale: The newborn infant with RDS may present with clinical manifestation of cyanosis, tachypnea or apnea, chest wall retractions, audible grunts, or nasal flaring. Acrocyanosis, the bluish discoloration of the hands and feet, is associated with immature peripheral circulation and is not uncommon in the first few hours of life.
A newborn infant is diagnosed with esophageal atresia. Which assessment finding supports this diagnosis?
- A. Slowed reflexes
- B. Continuous drooling
- C. Diaphragmatic breathing
- D. Passage of large amounts of frothy stool
Correct Answer: B
Rationale: In esophageal atresia, the esophagus terminates before it reaches the stomach, ending in a blind pouch. This condition prevents the passage of swallowed mucus and saliva into the stomach. After fluid has accumulated in the pouch, it flows from the mouth and the infant then drools continuously. Responsiveness of the infant to stimulus would depend on the overall condition of the infant and is not considered a classic sign of esophageal atresia. Diaphragmatic breathing is not associated with this disorder. The inability to swallow amniotic fluid in utero prevents the accumulation of normal meconium, and lack of stools results.