The nurse is caring for a client who has experienced head trauma in a motor vehicle accident.
The client is having excessive urine output.
Which medication should the nurse anticipate administering?
Prednisolone (Prelone)
Corticotropin (ACTH or adrenocorticotropic hormone)
Vasopressin (Pitressin)
Calciferol (Ergocalciferol)
The Correct Answer is C
Choice A rationale:
Prednisolone is a corticosteroid that has anti-inflammatory and immunosuppressant effects. It does not have a direct effect on urine output.
While it may be used in some cases of head trauma to reduce inflammation, it would not be the first-line choice to address excessive urine output.
Prolonged use of prednisolone can have adverse effects such as fluid retention, weight gain, hypertension, and hyperglycemia.
Choice B rationale:
Corticotropin (ACTH) is a hormone that stimulates the adrenal glands to produce cortisol. Cortisol has a variety of effects, including increasing blood pressure and blood sugar levels.
It does not have a direct effect on urine output and would not be used to address this issue.
ACTH can have significant side effects, including fluid retention, electrolyte imbalances, and mood changes.
Choice C rationale:
Vasopressin is a hormone that regulates fluid balance in the body. It works by increasing water reabsorption in the kidneys, which can help to reduce urine output.
It is the most appropriate medication to administer to a client with excessive urine output following head trauma.
Vasopressin can be administered intravenously or subcutaneously. It is important to monitor the client's fluid intake and output closely when administering vasopressin, as it can lead to fluid overload if not used carefully.
Choice D rationale:
Calciferol is a form of vitamin D that helps to regulate calcium and phosphorus levels in the body. It does not have a direct effect on urine output.
It would not be used to address excessive urine output in a client with head trauma.
Excessive doses of calciferol can lead to hypercalcemia, which can cause kidney stones, bone pain, and other serious problems.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Calcium gluconate is the antidote for magnesium sulfate toxicity. It directly counteracts the effects of magnesium on the neuromuscular system, cardiovascular system, and central nervous system. It is essential to have calcium gluconate readily available at the bedside of any client receiving magnesium sulfate, as toxicity can occur quickly and without warning.
Mechanism of action:
Calcium gluconate competes with magnesium for binding sites on cell membranes and proteins. It displaces magnesium from these sites, thereby restoring normal cellular function.
Calcium gluconate also enhances calcium influx into cells, which further counteracts the effects of magnesium. Indications for use in magnesium sulfate toxicity:
Respiratory depression (respiratory rate <12 breaths per minute) Loss of deep tendon reflexes
Seizures
Cardiac arrhythmias (including heart block and cardiac arrest) Hypotension (systolic blood pressure <90 mmHg)
Dosage and administration:
The typical dose of calcium gluconate for magnesium sulfate toxicity is 1 gram (10 mL of a 10% solution) given IV push over 3- 5 minutes.
This dose may be repeated as needed, depending on the severity of the toxicity and the client's response to treatment. Nursing considerations:
Monitor the client's vital signs, respiratory status, and deep tendon reflexes closely during magnesium sulfate infusion and after administration of calcium gluconate.
Have a crash cart and code equipment readily available in case of cardiac arrest. Document the administration of calcium gluconate and the client's response to treatment.
Correct Answer is A
Explanation
Choice A rationale:
Requesting that the patient eat lunch first if testing is further delayed is the most appropriate action to prevent hypoglycemia for the following reasons:
1. Timing of NPH Insulin Peak:
NPH insulin is an intermediate-acting insulin with a peak action time of 4-12 hours after administration.
In this case, the patient received NPH insulin at 7:00 AM, meaning its peak effect is likely to occur between 11:00 AM and 5:00 PM.
Delaying lunch beyond 1:00 PM significantly increases the risk of hypoglycemia as the insulin's action peaks without adequate food intake to balance glucose levels.
2. Ensuring Consistent Mealtimes:
Consistency in meal timing is crucial for managing blood glucose levels in diabetic patients. Delaying meals can disrupt the balance between insulin and glucose, leading to hypoglycemia.
Prioritizing lunch at the usual time, even amidst testing delays, helps maintain a more predictable glucose pattern.
3. Addressing Acute Hypoglycemia Risk:
Hypoglycemia is a serious complication of diabetes that can occur if blood glucose levels fall too low. Symptoms can include shakiness, sweating, dizziness, confusion, and even loss of consciousness.
Promptly addressing potential delays in food intake is essential to prevent hypoglycemia and its associated risks.
Rationales for other choices:
Choice B: Discontinuing the evening dose of insulin does not address the immediate risk of hypoglycemia due to the missed lunch. It could lead to hyperglycemia later in the day or overnight.
Choice C: Saving the lunch tray for later may not be feasible if testing is significantly delayed. It also does not prevent hypoglycemia in the immediate timeframe.
Choice D: While a glass of orange juice can provide a quick source of glucose, it is a short-term solution and does not replace a balanced meal. It could also lead to a rapid rise in blood glucose followed by a subsequent drop.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.