The nurse is preparing a client for discharge who was recently diagnosed with Addison’s disease. Which instruction is most important for the nurse to include in this client’s discharge teaching plan?

Take prescribed cortisone accurately.

Use a walker when weakness occurs.

Avoid extreme environmental temperatures.

Increase daily intake of sodium in diet.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Taking prescribed cortisone accurately is the most important instruction for a client diagnosed with Addison’s disease. Cortisone is a type of glucocorticoid replacement therapy that helps to manage the symptoms of Addison’s disease and prevent adrenal crisis, a life-threatening condition characterized by acute insufficiency of adrenal hormones.
Choice B rationale
Using a walker when weakness occurs may be helpful for some clients with Addison’s disease, as muscle weakness is a common symptom. However, it is not the most important instruction. The primary treatment for Addison’s disease is hormone replacement therapy, which should help to alleviate symptoms such as muscle weakness.
Choice C rationale
Avoiding extreme environmental temperatures can be beneficial for individuals with Addison’s disease, as they may have difficulty regulating body temperature due to cortisol deficiency.
However, this is not the most important instruction. The cornerstone of managing Addison’s disease is hormone replacement therapy.
Choice D rationale
Increasing daily intake of sodium in the diet can be beneficial for some individuals with Addison’s disease, particularly during periods of gastrointestinal illness or intense physical activity. However, this is not the most important instruction. The primary treatment for Addison’s disease is hormone replacement therapy.

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Correct Answer is B

Explanation

Choice A rationale
Decreasing the flow rate of the irrigation solution is not the best action in this situation. The presence of blood clots in the tubing and collection bag indicates that the client may be experiencing clot retention, which can lead to urinary obstruction. Decreasing the flow rate may not provide sufficient force to dislodge clots from the catheter, which could exacerbate the problem.
Choice B rationale
Manually irrigating the catheter is the most appropriate action when blood clots are observed in the tubing and collection bag. Clots can obstruct the catheter and disrupt the continuous bladder irrigation, leading to urinary retention and increased discomfort for the client. Manual irrigation can help dislodge and remove these clots, ensuring the patency of the catheter and the effectiveness of the irrigation.
Choice C rationale
Discontinuing the infusion of the irrigation solution is not the best action in this situation. The purpose of continuous bladder irrigation after a transurethral resection of the prostate is to prevent clot formation and retention by continuously flushing the bladder. Discontinuing the infusion could lead to the formation of more clots, potentially causing urinary obstruction.
Choice D rationale
While monitoring catheter drainage is an important part of postoperative care, it is not the most appropriate action in this situation. The presence of blood clots in the tubing and collection bag indicates a potential problem that requires immediate intervention. Simply monitoring the situation without taking action to resolve it could lead to urinary obstruction and increased discomfort for the client.

A. Keep the head of the bed elevated until the treatment is completed. B. Instruct the client to drink plenty of fluids during the treatment. C. Monitor the client’s intravenous site hourly during the treatment. D. Administer an antiemetic before starting the chemotherapy.

Correct Answer is C

Explanation

Choice A rationale
Keeping the head of the bed elevated until the treatment is completed is not typically recommended to reduce the risk of vesicant extravasation during intravenous chemotherapy.
Choice B rationale
Instructing the client to drink plenty of fluids during the treatment does not directly reduce the risk of vesicant extravasation. Hydration can help maintain good vein health, but it does not prevent extravasation.
Choice C rationale
Monitoring the client’s intravenous site hourly during the treatment is a key action to reduce the risk of vesicant extravasation. Regular monitoring allows for early detection of any signs of extravasation, such as swelling or redness at the IV site.
Choice D rationale
Administering an antiemetic before starting the chemotherapy can help manage side effects such as nausea and vomiting, but it does not reduce the risk of vesicant extravasation.

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The nurse is preparing a client for discharge who was recently diagnosed with Addison’s disease. Which instruction is most important for the nurse to include in this client’s discharge teaching plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Which action should the nurse implement to reduce the risk of vesicant extravasation in the client who is receiving intravenous chemotherapy?

Correct Answer is C

Explanation

Following a transurethral resection of the prostate (TURP), a patient is discharged from the hospital with an indwelling urinary catheter. Which instruction is most important for the nurse to include in the discharge teaching plan?

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