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A nurse in intensive coronary care is caring for a client with an endotracheal tube who underwent coronary bypass surgery. The client awakens and attempts to communicate. Which nursing interventions should the nurse perform? Select all that apply.
- A. offer a communication board
- B. ask simple yes/no questions
- C. ask open-ended questions
- D. offer an electrolarynx
Correct Answer: A,B
Rationale: A communication board (A) and yes/no questions (B) facilitate communication for a client with an endotracheal tube. Open-ended questions (C) are difficult, and an electrolarynx (D) is for laryngeal issues.
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A nurse is following the progress of a client being treated for hypothyroidism. Which findings indicate the client is experiencing side effects of the thyroid replacement therapy? Select all that apply.
- A. excessive sweating
- B. constipation
- C. inability to tolerate cold
- D. leg cramps
Correct Answer: A,D
Rationale: Excessive sweating (A) and leg cramps (D) suggest hyperthyroidism from overmedication. Constipation (B) and cold intolerance (C) indicate under-treatment.
The nurse is caring for a client receiving warfarin therapy for atrial fibrillation. Laboratory results show an INR of 3.9. The nurse would expect which order from the health care provider?
- A. an order to increase the warfarin dose
- B. an order to decrease the warfarin dose
- C. an order for protamine sulfate
- D. no new order; the INR is therapeutic
Correct Answer: B
Rationale: INR 3.9 is above the therapeutic range (2-3 for atrial fibrillation), requiring a dose decrease (B). Protamine sulfate (C) is for heparin reversal.
The nurse is reviewing labs of a newly admitted client. Which lab result would prompt the nurse to contact the health care provider?
- A. ALT 33 units/L
- B. BNP 760 pg/mL
- C. WBC 10,450 mcL
- D. direct bilirubin 0.2 mg/dL
Correct Answer: B
Rationale: BNP 760 pg/mL indicates heart failure, requiring prompt provider notification. Other values are within normal ranges (ALT 7-56, WBC 4,000-11,000, direct bilirubin 0-0.3).
The nurse is teaching a newly admitted client about fall prevention. The nurse understands that which of the following interventions can help prevent client falls? Select all that apply.
- A. keep personal articles within reach
- B. explain the use of the call light system
- C. keep the bed in the lowest position with all side rails up
- D. dim the room lights so that the client can get adequate rest
- E. remind the client to call for assistance when getting out of bed
Correct Answer: A,B,E
Rationale: Keeping articles within reach (A), explaining the call light (B), and reminding to call for assistance (E) reduce fall risk. All side rails up (C) can increase risk, and dim lights (D) impair visibility.
A college student presents at the emergency department after being thrown off a horse. Head injury with increased intracranial pressure (ICP) is suspected. The nurse understands that late signs of increased ICP include which manifestations? Select all that apply.
- A. seizures
- B. irritability
- C. restlessness
- D. disorientation
- E. severe headache
- F. nausea and vomiting
Correct Answer: A,E,F
Rationale: Late signs of increased ICP include seizures (A), severe headache (E), and nausea/vomiting (F) due to brain compression. Irritability, restlessness, and disorientation are earlier signs.