Nokea
The healthcare provider is assessing a client who has returned from hemodialysis. Which finding requires immediate intervention?
- A. Weight gain of 1 pound.
- B. Dizziness.
- C. Fatigue.
- D. Muscle cramps.
Correct Answer: D
Rationale: After hemodialysis, muscle cramps can indicate an electrolyte imbalance, such as low potassium or magnesium levels, which requires immediate intervention to prevent potential complications like cardiac arrhythmias. Weight gain of 1 pound, dizziness, and fatigue are common post-hemodialysis symptoms that may not necessarily require immediate intervention unless they are severe or persisting.
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Prior to implementing a community health program targeting teenage smoking, which information is most important for the nurse to obtain?
- A. greater access to any healthcare provider
- B. allowance for early discharge
- C. Prevalence and patterns of smoking among teenagers
- D. approval by the network healthcare provider
Correct Answer: C
Rationale: The most important information for the nurse to obtain before implementing a community health program targeting teenage smoking is the prevalence and patterns of smoking among teenagers. Understanding this data is crucial to tailor the program to the specific needs and behaviors of the target group, ensuring it addresses the root causes effectively. Choices A, B, and D are unrelated to the specific needs of the target group and do not provide essential information for designing an effective smoking cessation program for teenagers.
The healthcare provider is caring for a client with hyperparathyroidism. Which laboratory result requires immediate intervention?
- A. Serum calcium of 11 mg/dL.
- B. Serum phosphorus of 3 mg/dL.
- C. Serum magnesium of 1.8 mg/dL.
- D. Serum albumin of 4 g/dL.
Correct Answer: A
Rationale: A serum calcium level of 11 mg/dL indicates hypercalcemia, which can be a complication of hyperparathyroidism and requires immediate intervention. Hypercalcemia can lead to serious complications such as cardiac dysrhythmias, renal failure, and neurologic symptoms. Monitoring and managing serum calcium levels are crucial in clients with hyperparathyroidism. Serum phosphorus, magnesium, and albumin levels are important to assess in clients with hyperparathyroidism, but they do not require immediate intervention as hypercalcemia poses a more urgent risk.
A client with chronic kidney disease is receiving erythropoietin therapy. Which finding indicates that the therapy is effective?
- A. Hemoglobin of 12 g/dL.
- B. Reticulocyte count of 1%.
- C. Blood pressure of 130/80 mm Hg.
- D. Serum ferritin level of 100 ng/mL.
Correct Answer: A
Rationale: The correct answer is A: Hemoglobin of 12 g/dL. Erythropoietin therapy stimulates red blood cell production, leading to an increase in hemoglobin levels. A hemoglobin level of 12 g/dL indicates that the therapy is effective in managing anemia associated with chronic kidney disease. Choice B, a reticulocyte count of 1%, is not a direct indicator of the effectiveness of erythropoietin therapy. Choice C, a blood pressure of 130/80 mm Hg, is important to monitor in clients with chronic kidney disease but does not specifically indicate the effectiveness of erythropoietin therapy. Choice D, a serum ferritin level of 100 ng/mL, is related to iron stores in the body and may be monitored during erythropoietin therapy but does not directly reflect the therapy's effectiveness in increasing red blood cell production.
A client with a history of coronary artery disease is admitted with chest pain. Which finding requires immediate intervention?
- A. Heart rate of 90 beats per minute.
- B. Blood pressure of 130/80 mm Hg.
- C. Respiratory rate of 20 breaths per minute.
- D. Chest pain radiating to the left arm.
Correct Answer: D
Rationale: The correct answer is D. Chest pain radiating to the left arm can be a sign of myocardial infarction (heart attack) and requires immediate intervention. This symptom is known as a classic presentation of a heart attack and warrants urgent medical attention to prevent further cardiac damage. Choices A, B, and C are not directly indicative of an acute cardiac event and may not require immediate intervention in this scenario. While heart rate, blood pressure, and respiratory rate are important vital signs to monitor, they do not specifically indicate the urgency associated with chest pain radiating to the left arm in a patient with a history of coronary artery disease.
The school nurse is developing an individualized healthcare plan for a student with type 1 diabetes. Which component is most important to include in the plan?
- A. a schedule for blood glucose monitoring
- B. a list of low-carbohydrate snacks
- C. a contact list of healthcare providers
- D. a log for recording insulin administration
Correct Answer: A
Rationale: The correct answer is A: a schedule for blood glucose monitoring. Regular blood glucose monitoring is essential in managing type 1 diabetes as it helps in monitoring blood sugar levels, adjusting treatment plans, and preventing complications such as hypoglycemia or hyperglycemia. Choice B, a list of low-carbohydrate snacks, while important for managing blood sugar levels, is not as critical as consistent blood glucose monitoring. Choice C, a contact list of healthcare providers, though important for emergency situations, is not the most crucial component in managing daily care. Choice D, a log for recording insulin administration, is valuable for tracking insulin doses but does not directly address the immediate need for monitoring blood glucose levels.