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A nurse is admitting a client who reports tightness in their chest that radiates to left arm. Which of the following findings require immediate follow-up?
- A. Temperature 37.1° C (98.8° F)
- B. Heart rate 110/min and irregular
- C. Respiratory rate 24/min
- D. Blood pressure 164/80 mm Hg
- E. Oxygen saturation 93% on room air
Correct Answer: B
Rationale: The correct answer is B: Heart rate 110/min and irregular. This finding suggests cardiac distress or arrhythmia, which could indicate a heart attack. Immediate follow-up is necessary to assess the client's cardiac status and intervene promptly.
Incorrect choices:
A: Temperature within normal range.
C: Respiratory rate within normal range.
D: Blood pressure slightly elevated but not an immediate concern.
E: Oxygen saturation slightly low but not critically low.
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A nurse is administering furosemide 80 mg PO twice daily to a client who has pulmonary edema. Which of the following assessment findings indicates to the nurse that the medication is effective?
- A. Adventitious breath sounds
- B. Respiratory rate of 24/min
- C. Weight loss of 1.8 kg (4 lb) in the past 24 hr
- D. Elevation in blood pressure
Correct Answer: C
Rationale: The correct answer is C: Weight loss of 1.8 kg (4 lb) in the past 24 hr. Furosemide is a diuretic that helps to reduce fluid retention, so weight loss indicates the medication is effectively reducing pulmonary edema. Adventitious breath sounds indicate respiratory issues, not medication effectiveness. A respiratory rate of 24/min could be within normal range and not necessarily indicative of medication effectiveness. Elevation in blood pressure could indicate a potential adverse effect of furosemide, not effectiveness. Weight loss is the most direct indicator of reduced fluid volume due to diuresis.
A nurse is assessing a client who has increased intracranial pressure. The nurse should recognize that which of the following is the first sign of deteriorating neurological status?
- A. Altered level of consciousness
- B. Cheyne-Stokes respirations
- C. Decorticate posturing
- D. Pupillary dilation
Correct Answer: A
Rationale: The correct answer is A: Altered level of consciousness. This is the first sign of deteriorating neurological status in a client with increased intracranial pressure. Changes in consciousness indicate impairment in brain function, signaling potential brain injury or worsening condition. Altered level of consciousness can progress rapidly if not addressed promptly.
Choice B, Cheyne-Stokes respirations, is associated with abnormal breathing patterns and typically occurs in conditions like heart failure or brain injury, but it is not the first sign of neurological deterioration.
Choice C, Decorticate posturing, is a sign of brain injury but typically occurs after alterations in consciousness.
Choice D, pupillary dilation, can be a sign of increased intracranial pressure, but it usually occurs after alterations in consciousness.
A nurse is planning care for a client who is 12 hr postoperative following a kidney transplant. Which of the following actions should the nurse include in the plan of care?
- A. Check the client's blood pressure every 8 hr.
- B. Assess urine output hourly.
- C. Administer opioids PO.
- D. Monitor for hypokalemia as a manifestation of acute rejection.
Correct Answer: B
Rationale: The correct answer is B: Assess urine output hourly. This is important postoperatively to monitor kidney function and ensure adequate perfusion. Hourly assessment allows for early detection of any changes in urine output, which can indicate complications such as acute kidney injury. Checking blood pressure every 8 hours (Choice A) may be necessary but is less critical in the immediate postoperative period. Administering opioids PO (Choice C) can mask changes in the client's condition and should be avoided until kidney function is stable. Monitoring for hypokalemia (Choice D) is important but not the priority in the immediate postoperative period.
A nurse is caring for a client who has COPD. Which of the following findings require immediate follow-up?
- A. Client is oriented to person, place, and time.
- B. Client is restless.
- C. Pupils are reactive to light.
- D. Client is tachypneic, cough is productive, and mucous is yellow in color.
- E. Wheezes and crackles heard upon auscultation.
Correct Answer: D
Rationale: The correct answer is D. Tachypnea, productive cough with yellow mucus in a client with COPD indicate a potential exacerbation requiring immediate follow-up. Tachypnea suggests respiratory distress, while yellow mucus may indicate infection. Prompt intervention can prevent worsening respiratory status. Choices A, B, and C do not indicate acute respiratory distress. Option E may be concerning but doesn't necessitate immediate intervention like option D does.
A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?
- A. Photophobia
- B. Bradycardia
- C. Intermittent headache
- D. Petechiae on the chest
Correct Answer: A
Rationale: The correct answer is A: Photophobia. Meningitis is an inflammation of the meninges, the protective membranes covering the brain and spinal cord. Photophobia, or sensitivity to light, is a classic symptom of meningitis due to the irritation of the meninges causing increased sensitivity to light. This occurs because the inflamed meninges lead to stimulation of the nerves around the brain, resulting in discomfort when exposed to light.
Bradycardia (B) is not typically associated with meningitis. Intermittent headache (C) is vague and can be present in various conditions. Petechiae on the chest (D) are more commonly seen in conditions like meningococcal meningitis.