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A nurse is assessing a client who is 30 minutes postoperative following an arterial thrombectomy. What should the nurse report?
- A. Chest pain.
- B. Muscle spasms.
- C. Cool, moist skin.
- D. Incisional pain.
Correct Answer: A
Rationale: In this scenario, postoperative chest pain is a critical finding that must be reported promptly. Chest pain after an arterial thrombectomy could indicate serious complications such as myocardial infarction or pulmonary embolism. Muscle spasms and cool, moist skin are not the priority assessments in this situation. Incisional pain is common after surgery and is not typically a cause for immediate concern unless it is severe and accompanied by other symptoms.
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A nurse is caring for a client who is 1 hour postpartum. Which of the following findings should the nurse report to the provider?
- A. Fundus firm and at the umbilicus.
- B. Heart rate 80/min.
- C. Blood pressure 130/78 mm Hg.
- D. A constant trickle of bright red blood from the vagina.
Correct Answer: D
Rationale: After childbirth, it is normal for the fundus to be firm and at the level of the umbilicus, heart rate to be around 80/min, and blood pressure to be slightly elevated. However, a constant trickle of bright red blood from the vagina is concerning as it could indicate postpartum hemorrhage. This finding should be reported promptly to the healthcare provider for further evaluation and intervention. Choices A, B, and C are within expected postpartum parameters and do not indicate an immediate need for intervention.
A client with osteoporosis is being taught about dietary management. Which of the following foods should be recommended?
- A. Almonds
- B. Spinach
- C. Yogurt
- D. Carrots
Correct Answer: C
Rationale: Yogurt is a calcium-rich food that helps strengthen bones and should be recommended to clients with osteoporosis. Almonds, spinach, and carrots do not provide as much calcium as yogurt and are not as beneficial for individuals with osteoporosis.
A nurse is caring for a client who has severe hypertension and is receiving nitroprusside. What action should the nurse take?
- A. Administer oxygen and assess the client's response.
- B. Monitor blood pressure every 2 hours.
- C. Limit light exposure to the IV infusion.
- D. Attach an inline filter to the IV tubing.
Correct Answer: C
Rationale: The correct action for the nurse to take when caring for a client receiving nitroprusside for severe hypertension is to limit light exposure to the IV infusion. Nitroprusside is light-sensitive, and exposure to light can lead to degradation of the medication, reducing its effectiveness. Administering oxygen (Choice A) may be necessary for some clients but is not directly related to the administration of nitroprusside. Monitoring blood pressure every 2 hours (Choice B) is a general nursing intervention for clients with hypertension but does not specifically address the administration of nitroprusside. Attaching an inline filter to the IV tubing (Choice D) is not necessary to address the specific concern of light exposure related to nitroprusside administration.
A client is being discharged with a new prescription for metoprolol. Which of the following instructions should the nurse include?
- A. Do not discontinue this medication suddenly.
- B. Take this medication in the evening to decrease the risk of falls.
- C. Monitor your heart rate before taking this medication.
- D. Avoid grapefruit juice while taking this medication.
Correct Answer: C
Rationale: The correct instruction for a client prescribed metoprolol is to monitor their heart rate before taking the medication. Metoprolol is a beta-blocker that can cause bradycardia (slow heart rate), so it is essential for clients to check their heart rate before each dose. Choice A is incorrect because abruptly stopping metoprolol can lead to adverse effects, so it should not be discontinued suddenly. Choice B is incorrect because there is no specific recommendation to take metoprolol at night to reduce falls. Choice D is incorrect because grapefruit juice can interact with metoprolol, affecting its absorption, and should be avoided.
A client with a history of depression is experiencing a situational crisis. Which of the following actions should the nurse take first?
- A. Confirm the client's perception of the event.
- B. Notify the client's support system.
- C. Help the client identify personal strengths.
- D. Teach the client relaxation techniques.
Correct Answer: A
Rationale: The correct answer is to confirm the client's perception of the event. In crisis intervention, understanding the client's perspective is crucial as it helps the nurse assess the situation accurately and provide tailored support. This step can also help build rapport and trust with the client. Option B, notifying the client's support system, may be important but should come after assessing the client's perception. Option C, helping the client identify personal strengths, and option D, teaching relaxation techniques, are valuable interventions but should follow the initial step of confirming the client's perception.