Nokea
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.
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A nurse is preparing a teaching plan for a client who has mucositis related to chemotherapy treatment. Which of the following instructions should the nurse include?
- A. Brush your teeth for 60 seconds twice daily.
- B. Wear your dentures only during meals.
- C. Floss your teeth gently following each meal.
- D. Rinse your mouth with hydrogen peroxide.
Correct Answer: B
Rationale: The correct answer is B: Wear your dentures only during meals. This instruction is important for a client with mucositis because wearing dentures continuously can exacerbate irritation and discomfort in the mouth. By removing dentures between meals, the client can allow the oral tissues to rest and promote healing.
Choice A is incorrect because vigorous brushing for 60 seconds can further irritate the mucositis. Choice C is incorrect as flossing can also cause trauma to the inflamed tissues. Choice D is incorrect as rinsing with hydrogen peroxide can be too harsh and may worsen the condition. It's important to provide gentle care and minimize irritation to the affected areas in mucositis.
A nurse is preparing to administer daily medications to a client who is undergoing a procedure at 1000 that requires IV contrast dye. Which of the following routine medications to give at 0800 should the nurse withhold?
- A. Fluticasone
- B. Metoprolol
- C. Metformin
- D. Valproic acid
Correct Answer: C
Rationale: The correct answer is C: Metformin. The nurse should withhold metformin before the procedure with IV contrast dye due to the risk of lactic acidosis. IV contrast dye can affect kidney function, leading to an increased risk of lactic acidosis when combined with metformin. Fluticasone (A), metoprolol (B), and valproic acid (D) are not contraindicated before the procedure with IV contrast dye. Fluticasone is an inhaled corticosteroid, metoprolol is a beta-blocker, and valproic acid is an anticonvulsant. These medications are not typically affected by IV contrast dye and can be safely administered.
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 assessing a client who recently had a myocardial infarction. Which of the following findings indicates that the client might be developing pulmonary edema?
- A. Excessive somnolence
- B. Epistaxis
- C. Pink
- D. frothy sputum
- E. Tachypnea
Correct Answer: C
Rationale: The correct answer is C: Pink frothy sputum. This finding indicates pulmonary edema, which is characterized by fluid accumulation in the lungs. The pink color indicates the presence of blood in the sputum, a common sign of pulmonary edema. Excessive somnolence (A) is more indicative of respiratory depression or hypoxia, while epistaxis (B) is associated with hypertension or nasal trauma. Tachypnea (E) can be a sign of respiratory distress but does not specifically indicate pulmonary edema.
A nurse is assessing a client who has a chest tube connected to a closed water-seal drainage system. Which of the following findings should the nurse report to the provider?
- A. Constant bubbling in the water seal chamber
- B. Intermittent bubbling in the suction chamber
- C. Clear drainage of 50 mL over 8 hours
- D. Mild pain at the insertion site
Correct Answer: A
Rationale: The correct answer is A: Constant bubbling in the water seal chamber. Constant bubbling in the water seal chamber indicates an air leak in the chest tube system, which can lead to lung collapse or pneumothorax. This finding should be reported to the provider immediately for further evaluation and intervention. Intermittent bubbling in the suction chamber (choice B) is expected and indicates that the suction is working properly. Clear drainage of 50 mL over 8 hours (choice C) is within normal limits and does not require immediate reporting. Mild pain at the insertion site (choice D) is common after a chest tube insertion and can be managed with pain medication.