After performing a head-to-toe assessment for a client with Addison's disease, the nurse reports findings to the healthcare provider. The findings include moist mucous membranes, strong palpable peripheral pulses, and blood pressure 132/88 mm Hg. The client verbalizes understanding of the illness and importance of taking medications every day. Which action should the nurse implement?

Make a referral for social services at home.

Continue to limit daily fluid intake to 500 mL.

Begin preparing the client for discharge home.

Recommend strict intake and output monitoring.

Answer and Explanation

The Correct Answer is C

Choice A reason: A referral for social services at home is not necessary for a client with Addison's disease who has stable vital signs, adequate hydration, and good self-care knowledge.

Choice B reason: Limiting daily fluid intake to 500 mL is not appropriate for a client with Addison's disease, who is at risk of dehydration and hypotension. The client should drink fluids according to thirst and urine output.

Choice C reason: Preparing the client for discharge home is the best action for the nurse to implement, as the client has no signs of complications or deterioration from Addison's disease. The client should be able to manage the condition at home with regular follow-up and medication adherence.

Choice D reason: Strict intake and output monitoring is not required for a client with Addison's disease who has normal blood pressure, moist mucous membranes, and strong peripheral pulses. These indicate adequate fluid balance and renal function.

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Correct Answer is C

Explanation

Choice A reason: Lifting and clearing drainage from the chest tube is not necessary, as the water level fluctuations indicate that the chest tube is functioning properly and allowing air and fluid to escape from the pleural space.

Choice B reason: Inspecting the tube insertion site for leaking is not indicated, as there is no evidence of air leak in the water-seal chamber. An air leak would cause continuous or intermittent bubbling in the water-seal chamber.

Choice C reason: Continuing to monitor the drainage system is the best action for the nurse to implement, as the water level fluctuations are normal and expected in a water-seal drainage system. The water level should rise during inspiration and fall during expiration, reflecting the changes in intrathoracic pressure.

Choice D reason: Auscultating lungs for unequal breath sounds is not relevant, as it does not address the question of what to do with the water level fluctuations. Unequal breath sounds may indicate a pneumothorax or atelectasis, which are complications of chest trauma or chest tube insertion.

A. Sodium polystyrene sulfonate 15 grams by mouth. B. Sevelamer one tablet by mouth. C. Calcium acetate one tablet by mouth. D. Epoetin alfa, recombinant 2,500 units subcutaneously.

Correct Answer is A

Explanation

Choice A reason: Sodium polystyrene sulfonate is a medication that binds to excess potassium in the gastrointestinal tract and removes it from the body through feces. It is used to treat hyperkalemia, which is a high level of potassium in the blood. Hyperkalemia can cause cardiac arrhythmias and muscle weakness, and it is a common complication of AKI. Therefore, this medication should be administered first to lower the potassium level and prevent life-threatening complications.

Choice B reason: Sevelamer is a medication that binds to phosphorus in the gastrointestinal tract and removes it from the body through feces. It is used to treat hyperphosphatemia, which is a high level of phosphorus in the blood. Hyperphosphatemia can cause bone loss and soft tissue calcification, and it is a common complication of chronic kidney disease (CKD). However, it is not an urgent issue in AKI, and it does not affect the potassium level.

Choice C reason: Calcium acetate is a medication that also binds to phosphorus in the gastrointestinal tract and removes it from the body through feces. It has the same effect and indication as sevelamer, but it also provides calcium supplementation. However, it is not an urgent issue in AKI, and it does not affect the potassium level.

Choice D reason: Epoetin alfa, recombinant is a medication that stimulates the production of red blood cells in the bone marrow. It is used to treat anemia, which is a low level of hemoglobin or red blood cells in the blood. Anemia can cause fatigue, weakness, and shortness of breath, and it is a common complication of CKD and AKI. However, it is not an urgent issue in AKI, and it does not affect the potassium level.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A client with acute renal injury (AKI) weighs 110.3 pounds (50 kg) and has a potassium level of 6.7 mEq/L (6.7 mmol/L) is admitted to the hospital. Which prescribed medication should the nurse administer first? Reference Range: Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)]

Correct Answer is A

Explanation

Exhibits The nurse is reviewing the physician orders. Which of the following physician’s orders requires priority attention from the nurse? Select all that apply.

Five months following treatment for Herpes zoster (shingles), an older adult client tells the home health nurse of continuing to experience pain where the rash occurred. Which action should the nurse implement?

The nurse is providing dietary instructions for a client who is being discharged after passing a calcium oxalate renal stone. Which food should the nurse instruct the client to avoid?

The nurse is caring for a client with chemotherapy-induced mucositis who is describing soreness of the tongue and oral issues. Which is the best initial nursing action?

Exhibits For each assessment finding, explain whether the actions taken were effective or ineffective.

In assessing a client with ulcers on the lower extremity, which findings indicate that the ulcers are likely to be of venous, rather than arterial, origin?