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A client with newly diagnosed hypertension is being taught about lifestyle modifications by a nurse. Which client statement indicates a need for further teaching?
- A. 'I will reduce my salt intake to help manage my blood pressure.'
- B. 'I will start exercising regularly to help control my blood pressure.'
- C. 'I will avoid drinking alcohol to help manage my blood pressure.'
- D. 'I will limit my caffeine intake to help control my blood pressure.'
Correct Answer: D
Rationale: The correct answer is D. Limiting caffeine intake is a positive lifestyle modification for managing hypertension. The statement indicates that the client understands the importance of reducing caffeine intake. Choices A, B, and C all reflect appropriate lifestyle modifications for managing hypertension, indicating good understanding by the client.
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A client with a history of hypertension is admitted with a blood pressure of 200/110 mmHg. Which intervention should the nurse implement first?
- A. Administer an antihypertensive medication as prescribed.
- B. Monitor the client's urine output.
- C. Administer oxygen therapy as prescribed.
- D. Obtain an arterial blood gas (ABG) sample.
Correct Answer: D
Rationale: The correct answer is to obtain an arterial blood gas (ABG) sample. In a client with severe hypertension, it is essential to assess for metabolic or respiratory acidosis which can be done through an ABG sample. Administering antihypertensive medication without assessing the acid-base status of the client can lead to potential complications. Monitoring urine output and administering oxygen therapy are important interventions but are not the priority in this situation where the focus should be on assessing acidosis.
While auscultating a client's heart sounds, which description should the nurse use to document a swishing sound related to blood turbulence or valvular defect?
- A. S1 S2
- B. S1 S2 S3
- C. Murmur
- D. Pericardial friction rub
Correct Answer: C
Rationale: The correct answer is 'C: Murmur.' A murmur is auscultated as a swishing sound associated with blood turbulence caused by the heart or a valvular defect. Choices 'A: S1 S2' and 'B: S1 S2 S3' refer to normal heart sounds, specifically the closure of heart valves. 'D: Pericardial friction rub' is a dry, rubbing or grating sound caused by inflammation of the pericardial sac and is not associated with blood flow or valvular issues.
When administering ceftriaxone sodium (Rocephin) intravenously to a client, which finding requires the most immediate intervention by the nurse?
- A. Stridor
- B. Nausea
- C. Headache
- D. Pruritus
Correct Answer: A
Rationale: The correct answer is A: Stridor. Stridor indicates bronchospasm, a serious reaction that can compromise the client's airway. Immediate intervention is crucial to prevent further respiratory distress. Nausea, headache, and pruritus are potential side effects of ceftriaxone but are not as immediately life-threatening as airway compromise indicated by stridor.
A male client with impaired renal function who takes ibuprofen daily for chronic arthritis is admitted with gastrointestinal (GI) bleeding. After administering IV fluids and a blood transfusion, his blood pressure is 100/70, and his renal output is 20 ml/hour. Which intervention should the nurse include in care?
- A. Maintain the client NPO during the diuresis phase.
- B. Evaluate daily serial renal laboratory studies for progressive elevations.
- C. Observe the urine character for sedimentation and cloudy appearance.
- D. Monitor for onset of polyuria greater than 150ml/hour.
Correct Answer: B
Rationale: Evaluating daily renal laboratory studies is crucial in this scenario. The client has impaired renal function, recent GI bleeding, and is at risk for further kidney damage due to ibuprofen use. Monitoring renal labs helps assess kidney function and detect any progressive elevations, guiding further interventions. Option A is not directly related to renal function monitoring. Option C focuses more on urine appearance than renal function assessment. Option D mentions polyuria, which is excessive urine output, but the question describes a client with reduced renal output.
Which assessment finding of a postmenopausal woman necessitates a referral by the nurse to the healthcare provider for evaluation of thyroid functioning?
- A. Cold sensitivity.
- B. Hot flashes.
- C. Weight gain.
- D. Dry skin.
Correct Answer: A
Rationale: The correct answer is A: Cold sensitivity. Cold sensitivity is a common symptom of hypothyroidism, a condition that affects the thyroid gland's ability to produce enough hormones. As a postmenopausal woman presents with cold sensitivity, it may indicate an underlying thyroid issue. Hot flashes (choice B) are more commonly associated with menopause than thyroid dysfunction. While weight gain (choice C) and dry skin (choice D) can also be symptoms of thyroid disorders, cold sensitivity is more specific and indicative of hypothyroidism, requiring prompt evaluation by a healthcare provider.