Nokea
A 56-year-old woman is admitted for a modified radical mastectomy. The client appears anxious and asks many questions. The nurse's best course of action is to:
- A. Tell the client as much as she wants to know and is able to understand.
- B. Delay discussing the client's questions with her until the convalescent phase of her care.
- C. Delay discussing the client's questions with her until her apprehension subsides.
- D. Explain to the client that she should discuss her questions with her physician.
Correct Answer: A
Rationale: Addressing the client's questions thoroughly and at her level of understanding reduces anxiety and supports informed consent.
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A client with a history of heart failure is admitted with fatigue. The nurse should monitor the client for which of the following laboratory abnormalities?
- A. Elevated B-type natriuretic peptide (BNP).
- B. Decreased creatinine.
- C. Increased albumin.
- D. Decreased sodium.
Correct Answer: A, D
Rationale: Elevated BNP indicates heart failure severity, and hyponatremia is common due to fluid overload.
The nurse reviews the serum laboratory results for a client prescribed hydrochlorothiazide. Which most frequent side effect of this medication should the nurse specifically monitor for?
- A. Hypokalemia
- B. Hypocalcemia
- C. Hypernatremia
- D. Hyperphosphatemia
Correct Answer: A
Rationale: The client taking a potassium-losing diuretic must be monitored for decreased potassium levels. Other fluid and electrolyte imbalances that occur with the use of this medication include hyponatremia, hypercalcemia, hypomagnesemia, and hypophosphatemia.
Which client should the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. A client who needs teaching regarding the use of an incentive spirometer
- B. A client who needs to have a urine specimen collected for a clean catch urine
- C. A client who needs reinforcement of a dressing covering an abdominal incision
- D. A client who needs assessment of a newly identified area of pressure over the right hip
Correct Answer: B
Rationale: The UAP can assist with specimen collection such as a clean catch urine because he or she is trained in this skill. Skills requiring nursing intervention such as dressing changes, teaching, and assessment cannot be delegated to unlicensed personnel.
A client with a history of heart failure is prescribed eplerenone (Inspra). The nurse should monitor the client for which of the following side effects?
- A. Hyperkalemia.
- B. Hypoglycemia.
- C. Weight gain.
- D. Hypertension.
Correct Answer: A
Rationale: Eplerenone, a potassium-sparing diuretic, can cause hyperkalemia, requiring monitoring of potassium levels.
The nurse is administering propranolol (Inderal) to a client for control of migraine headaches. The client's pulse rate is 56 bpm. What should the nurse do next?
- A. Contact the physician immediately.
- B. Assess blood pressure.
- C. Administer oxygen.
- D. Ask for a relative to contact.
Correct Answer: A
Rationale: Propranolol, a beta-blocker, can cause bradycardia. A pulse of 56 bpm is concerning and warrants immediate physician notification to evaluate the need for dose adjustment or intervention.