NCLEX Certification NCLEX-RN Release Date

(A) The first nursing measure is to instruct the client in which drug side effects to report. (B) Discontinuing the drug is not an independent nursing intervention and may compromise client care. (C) Audiometric testing will detect hearing loss, but it does not indicate a potential cause. (D) Equalizing middle ear pressure will not prevent hearing loss.

(A) This action does nothing to prepare the child and her family for what will happen or to relieve their anxiety and fear. (B) This action provides security by preparing the child and the family for what will happen and will help to relieve fear and anxiety. (C) This action does nothing to help prepare the child for what will happen and does not give the parents permission to ask questions until later. (D) This action provides possibly false reassurance and may prevent the child and/or the family from asking pressing questions.

(A) Sodium polystyrene sulfonate administration will not increase serum magnesium. Hypermagnesemia is virtually unknown except for clients in renal failure. (B) Sodium polystyrene sulfonate administration is not known to increase serum bicarbonate. (C) Decrease in serum potassium, the expected response of sodium polystyrene sulfonate, is secondary to the binding of this drug and potassium in the colon, and potassium is removed through the feces. (D) Serum calcium may actually increase with sodium polystyrene sulfonate administration, especially if calcium chloride is administered concurrently with this drug.

(A) Assessment should focus on detection of tetany, which is the most common symptom of hypoparathyroidism. Left undetected and untreated, tetany resulting from hypocalcemia can progress to seizures. (B) Hypocalcemia is difficult to detect on nursing assessment alone. Abdominal cramping may be an indication of hypocalcemia, but laboratory data are required to confirm diagnosis. (C) Depression can be a symptom of hypoparathyroidism, but it is not definitive. (D) Premature cataract formation can occur, but it also is not specific to parathyroidism and poses no immediate danger to the client.