The healthcare provider prescribes aluminum and magnesium hydroxide
(Maalox), 1 tablet PO PRN, for a client with chronic kidney disease (CKD)
who is complaining of indigestion. What intervention should the nurse
implement?
a. Administer 30 minutes before eating.
b. Evaluate the effectiveness 1 hour after administration.
c. Instruct the client to swallow the tablet whole.
d.Question the healthcare provider's prescription. Correct answers d.
Question the healthcare provider's prescription.
Rationale
Magnesium agents are not usually used for clients with CKD due to
the risk of hypermagnesemia, so this prescription should be
questioned by the nurse.
In assessing a client diagnosed with primary hyperaldosteronism, the nurse
expects the laboratory test results to indicate a decreased serum level of
which substance?
Sodium.
Antidiuretic
hormone.
Potassium.
Glucose. Correct
answers Potassium
Rationale
Clients with primary hyperaldosteronism exhibit a profound decline in the
serum levels of potassium (hypokalemia). Hypertension, along with the
hypokalemia are the most prominent and universal signs for this condition.
If both of these findings are present, there is 50% likelihood the client to be
diagnosed with hyperaldosteronism.
A client with gastroesophageal reflux disease (GERD) has been
experiencing severe reflux during sleep. Which recommendation by the
nurse is most effective to assist the client?
Losing weight.
Decreasing caffeine
intake. Avoiding large
meals.
Raising the head of the bed on blocks. Correct answers Raising the head of
the bed on blocks.
Rationale
, Raising the head of the bed on blocks (reverse Trendelenburg position) to
reduce reflux and subsequent aspiration is the most non-pharmacological
effective recommendation for a client experiencing severe gastroesophageal
reflux during sleep.
A client with diabetes mellitus is experiencing polyphagia. Which outcome
statement is the priority for this client?
Fluid and electrolyte
balance. Prevention of
water toxicity.
Reduced glucose in the
urine.
Adequate cellular
nourishment. Correct
answers Adequate
cellular nourishment.
Rationale
Diabetes mellitus Type 1 is characterized by hyperglycemia that precipitates
glucosuria and polyuria (frequent urination), polydipsia (excessive thirst),
and polyphagia (excessive hunger). Polyphagia is a consequence of cellular
malnourishment when insulin deficiency prevents utilization of glucose into
the cell for energy, so the outcome statement should include stabilization of
adequate cellular nutrition which is done by providing the insulin
supplement the client needs.
An elderly client is admitted with a diagnosis of bacterial pneumonia.
The nurse's assessment of the client will most likely reveal which
sign/symptom?
Leukocytosis and
febrile. Polycythemia
and crackles.
Pharyngitis and sputum
production.
Confusion and
tachycardia. Correct
answers Confusion and
tachycardia.
Rationale
The onset of pneumonia in the elderly may be signaled by general
deterioration, confusion, increased heart rate or increased respiratory
rate due to the decreased oxygen- carbon dioxide exchange at the
alveoli, known as the V-Q mismatch.
A client with a 16-year history of diabetes mellitus is having renal function
tests because of recent fatigue, weakness, elevated blood urea nitrogen, and
serum creatinine levels. Which finding should the nurse conclude as an early
symptom of renal insufficiency?
Dyspnea.
Nocturia.
Confusio
n.
Stomatiti