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The nurse is assessing a client with left-sided heart failure. Which finding should be reported to the healthcare provider immediately?
- A. Shortness of breath
- B. Jugular venous distention
- C. Crackles in the lungs
- D. Elevated liver enzymes
Correct Answer: C
Rationale: In a client with left-sided heart failure, the presence of crackles in the lungs is the most critical finding that should be reported to the healthcare provider immediately. Crackles indicate pulmonary congestion, which requires prompt intervention to prevent respiratory compromise. Shortness of breath, though a common symptom in heart failure, is a result of pulmonary congestion, making crackles a more direct indicator of the severity of the condition. Jugular venous distention and elevated liver enzymes are important to assess in heart failure but are not as immediately concerning as crackles in the lungs, which directly reflect the impact of heart failure on the respiratory system.
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After a sudden loss of consciousness, a female client is taken to the ED, and the initial assessment indicates that her blood glucose level is critically low. Once her glucose level is stabilized, the client reports that she was recently diagnosed with anorexia nervosa and is being treated at an outpatient clinic. Which intervention is most important to include in this client's discharge plan?
- A. Describe the signs and symptoms of hypoglycemia.
- B. Encourage a low-carbohydrate and high-protein diet.
- C. Reinforce the need to continue outpatient treatment.
- D. Suggest wearing a medical alert bracelet at all times.
Correct Answer: B
Rationale: Encouraging a low-carbohydrate and high-protein diet is crucial for a client recovering from anorexia nervosa to prevent hypoglycemic episodes. Choice A is not the most important intervention at this point since the client is already aware of hypoglycemia based on the recent event. Choice C is important but not the priority in this situation where dietary intervention is crucial. Choice D, suggesting a medical alert bracelet, is not as essential as ensuring proper nutrition to prevent further hypoglycemic episodes.
A client with chronic obstructive pulmonary disease (COPD) is experiencing shortness of breath and has a prescription for oxygen therapy. What is the maximum amount of oxygen the nurse should administer without a healthcare provider's order?
- A. 2 liters per minute
- B. 4 liters per minute
- C. 6 liters per minute
- D. 8 liters per minute
Correct Answer: B
Rationale: The correct answer is 4 liters per minute. Without a healthcare provider's order, the nurse should administer a maximum of 4 liters per minute of oxygen to prevent carbon dioxide retention in COPD clients. Higher flow rates can lead to oxygen toxicity and worsen the client's condition. Choices A, C, and D exceed the safe limit for oxygen administration without a healthcare provider's order.
The home health nurse is preparing to make daily visits to a group of clients. Which client should the nurse visit first?
- A. A client with congestive heart failure who reports a 3-pound weight gain in the last two days
- B. A client with a healing surgical wound
- C. A client requiring wound dressing change
- D. A client with stable vital signs needing medication administration
Correct Answer: A
Rationale: The correct answer is A. A 3-pound weight gain in two days indicates fluid retention and worsening heart failure, which requires immediate assessment. This could be a sign of decompensation in the client's condition, necessitating prompt evaluation and intervention. Choices B, C, and D do not present an immediate threat to the client's health and can be addressed after assessing the client with congestive heart failure.
The nurse is caring for a client with a chest tube following a pneumothorax. Which assessment finding requires immediate intervention?
- A. Oxygen saturation of 94%
- B. Subcutaneous emphysema
- C. Crepitus around the insertion site
- D. Drainage of 50 ml per hour
Correct Answer: B
Rationale: Subcutaneous emphysema is the correct answer as it is most concerning in a client with a chest tube following a pneumothorax. It may indicate a pneumothorax recurrence or air leak, requiring immediate intervention to prevent complications. Oxygen saturation of 94% is acceptable and does not require immediate intervention. Crepitus around the insertion site may be a normal finding after chest tube placement and does not necessarily indicate a complication. Drainage of 50 ml per hour is within the expected range for a chest tube and does not require immediate intervention.
A client is admitted for cellulitis surrounding an insect bite on the lower right arm, and intravenous (IV) antibiotic therapy is prescribed. Which action should the nurse implement before performing venipuncture?
- A. Lower the right arm below the level of the heart.
- B. Elevate the right arm on a pillow.
- C. Apply a tourniquet above the insertion site.
- D. Apply a warm compress to the insertion site.
Correct Answer: A
Rationale: Before performing venipuncture for IV therapy, the nurse should lower the right arm below the level of the heart. Lowering the arm helps dilate the veins, making it easier to locate and access a suitable vein for the procedure. Elevating the arm on a pillow, applying a tourniquet above the insertion site, or applying a warm compress to the insertion site are not appropriate actions before venipuncture as they can affect the venous blood flow and make the procedure more challenging.