Nokea
A client with diabetes mellitus is admitted with a blood glucose level of 600 mg/dl and is unresponsive. Which laboratory value is most concerning?
- A. Serum potassium of 3.0 mEq/L
- B. Serum glucose of 200 mg/dl
- C. Serum pH of 7.30
- D. Serum sodium of 135 mEq/L
Correct Answer: C
Rationale: In a client with Hyperosmolar Hyperglycemic State (HHS), a serum pH of 7.30 is the most concerning value as it indicates acidosis, a life-threatening condition that requires immediate intervention. Choices A, B, and D are not the most concerning in this scenario. A low serum potassium level (Choice A) may be expected due to cellular shift in hyperglycemia, a serum glucose level of 200 mg/dl (Choice B) is not as concerning compared to the extremely high initial glucose level, and a serum sodium level of 135 mEq/L (Choice D) is within the normal range and not the immediate priority.
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A client with a history of hypertension is prescribed a beta-blocker. Which client statement indicates that further teaching is needed?
- A. 'I will take my medication in the morning before breakfast.'
- B. 'I should avoid eating foods high in potassium.'
- C. 'I should change positions slowly to avoid dizziness.'
- D. 'I should avoid abrupt discontinuation of the medication.'
Correct Answer: B
Rationale: The correct answer is B: 'I should avoid eating foods high in potassium.' This statement indicates a misunderstanding as beta-blockers do not typically affect potassium levels. The other choices (A, C, and D) are all appropriate statements for a client prescribed a beta-blocker. Choice A shows understanding of the timing of medication administration, choice C addresses orthostatic hypotension concerns, and choice D highlights the importance of not abruptly stopping the medication to prevent adverse effects.
The nurse enters a client's room and observes the unlicensed assistive personnel (UAP) making an occupied bed. What action should the nurse take first?
- A. Place the side rails in an up position.
- B. Assist the UAP in turning the client.
- C. Provide instructions on proper bed-making techniques.
- D. Ask the client if they are comfortable.
Correct Answer: A
Rationale: The correct answer is to place the side rails in an up position first. This action is essential to prevent the client from falling while the bed is being made. Assisting the UAP in turning the client (Choice B) is not the immediate priority. Providing instructions on bed-making techniques (Choice C) can wait until the safety of the client is ensured. Asking the client if they are comfortable (Choice D) is important but should come after ensuring the client's safety by raising the side rails.
The nurse notes that a client who has undergone a thoracotomy has an increase in a large amount of dark red blood in the chest tube collection chamber. What action should the nurse take?
- A. Document the findings for this procedure as expected
- B. Notify the healthcare provider immediately
- C. Check the tube for kinks or dependent loops
- D. Increase the suction to the chest drainage system
Correct Answer: B
Rationale: An increase in a large amount of dark red blood in the chest tube collection chamber may indicate active bleeding. The nurse should notify the healthcare provider immediately to address the situation promptly and prevent further complications. Documenting the findings without taking immediate action could delay necessary interventions. Checking the tube for kinks or dependent loops is a good practice but not the priority when dealing with a potentially life-threatening situation like active bleeding. Increasing the suction without healthcare provider's orders can lead to complications and is not appropriate in this scenario.
The healthcare provider prescribes atenolol 50 mg daily for a client with angina pectoris. Which finding should the nurse report to the healthcare provider before administering this medication?
- A. Irregular pulse.
- B. Tachycardia.
- C. Chest pain.
- D. Urinary frequency.
Correct Answer: A
Rationale: The correct answer is A: Irregular pulse. An irregular pulse may indicate an arrhythmia, which could be exacerbated by atenolol, a beta-blocker used to treat angina pectoris. Atenolol works by slowing the heart rate, so if the patient already has an irregular pulse, it could worsen with the medication. Tachycardia (choice B) would actually be an expected finding in a patient with angina pectoris, and atenolol is used to help reduce the heart rate in such cases. Chest pain (choice C) is a symptom that atenolol is meant to alleviate, so it would not be a reason to withhold the medication. Urinary frequency (choice D) is not directly related to the administration of atenolol for angina pectoris and would not require immediate reporting to the healthcare provider.
The nurse is assessing a client with right-sided heart failure. Which finding requires immediate intervention?
- A. Jugular venous distention
- B. Peripheral edema
- C. Crackles in the lungs
- D. Elevated liver enzymes
Correct Answer: C
Rationale: In a client with right-sided heart failure, crackles in the lungs are the most concerning finding as they indicate pulmonary congestion, which requires immediate intervention. Crackles suggest fluid accumulation in the lungs, leading to impaired gas exchange and potential respiratory distress. Jugular venous distention (Choice A) and peripheral edema (Choice B) are common findings in right-sided heart failure but do not indicate acute deterioration requiring immediate intervention. Elevated liver enzymes (Choice D) may be seen in chronic heart failure but do not warrant immediate action compared to the urgent need to address pulmonary congestion indicated by crackles in the lungs.