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A client has a hemoglobin level of 7 g/dL. Which of the following findings should the nurse expect?
- A. Bounding pulses
- B. Elevated blood pressure
- C. Headache
- D. Pale, cool skin
Correct Answer: D
Rationale: Pale, cool skin is a common finding in clients with a hemoglobin level of 7 g/dL due to decreased oxygen carrying capacity. Bounding pulses (Choice A) are not typically associated with low hemoglobin levels. Elevated blood pressure (Choice B) is not a common finding in clients with anemia. While headache (Choice C) can occur with anemia, it is not a specific finding directly related to a hemoglobin level of 7 g/dL.
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A nurse is caring for a client who has heart failure and a prescription for digoxin. Which of the following findings should the nurse report to the provider?
- A. Heart rate of 60/min
- B. Respiratory rate of 16/min
- C. Sodium level of 138 mEq/L
- D. Weight gain of 1.5 kg (3.3 lb) in 24 hours
Correct Answer: D
Rationale: The correct answer is D. A weight gain of 1.5 kg (3.3 lb) in 24 hours can indicate fluid retention and worsening heart failure in clients taking digoxin. This rapid weight gain could be due to fluid accumulation, a common sign of heart failure exacerbation. Reporting this finding to the provider is crucial for prompt intervention. Choices A, B, and C are within normal ranges and not directly indicative of worsening heart failure in this context, making them less urgent to report compared to the significant weight gain.
A client is experiencing a panic attack. Which of the following actions should the nurse take first?
- A. Instruct the client to take deep, slow breaths.
- B. Administer an anti-anxiety medication.
- C. Remain with the client and offer reassurance.
- D. Encourage the client to use distraction techniques.
Correct Answer: C
Rationale: During a panic attack, the priority action for the nurse is to remain with the client and offer reassurance. This helps provide a sense of safety and security, which can aid in reducing the client's anxiety. Instructing the client to take deep, slow breaths (Choice A) can be beneficial but should come after providing immediate support. Administering medication (Choice B) should not be the first intervention unless deemed necessary by the healthcare provider. Encouraging distraction techniques (Choice D) may not be as effective initially as providing direct support and reassurance.
A client with heart failure is receiving discharge teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?
- A. I should weigh myself once a week.
- B. I should limit my fluid intake to 1 liter per day.
- C. I should report a weight gain of 2 pounds in one day.
- D. I should reduce my protein intake to prevent fluid retention.
Correct Answer: C
Rationale: The correct answer is C. Reporting a sudden weight gain of 2 pounds in one day is crucial in managing heart failure because it can indicate fluid retention, a common symptom in heart failure. Option A is incorrect as weighing oneself once a week may not provide timely information about fluid retention. Option B is incorrect because fluid intake restriction is individualized and generally involves more specific guidance. Option D is incorrect as protein intake is important but reducing it solely to avoid fluid retention is not the primary focus in heart failure management.
A client with COPD is receiving discharge teaching. Which statement indicates an understanding of the teaching?
- A. I will avoid breathing deeply while using my incentive spirometer.
- B. I will limit my fluid intake to 1 liter per day.
- C. I will exercise in an area that is humid.
- D. I will use pursed-lip breathing techniques.
Correct Answer: D
Rationale: The correct answer is D. Using pursed-lip breathing techniques is beneficial for clients with COPD as it helps control shortness of breath by keeping airways open longer. Option A is incorrect as deep breathing while using an incentive spirometer is essential to prevent complications such as atelectasis. Option B is incorrect because limiting fluid intake to 1 liter per day is not a standard recommendation for clients with COPD. Option C is incorrect as exercising in a humid area can exacerbate breathing difficulties for clients with COPD.
A client is postoperative following a thyroidectomy. Which of the following findings should the nurse identify as an indication of hypocalcemia?
- A. Constipation
- B. Numbness and tingling of the fingers
- C. Increased thirst
- D. Frequent urination
Correct Answer: B
Rationale: Numbness and tingling of the fingers are classic signs of hypocalcemia, a condition that may result from inadvertent damage to the parathyroid glands during a thyroidectomy. These symptoms occur due to decreased levels of calcium in the bloodstream affecting nerve function. Choices A, C, and D are not typical manifestations of hypocalcemia. Constipation is more associated with hypercalcemia, increased thirst can be seen in diabetes or dehydration, and frequent urination is a symptom more commonly linked to conditions like diabetes or urinary tract issues.