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A client is admitted to the emergency department 5 days after an acute coronary syndrome (ACS) troubled by severe fatigue, muscle weakness, and shortness of breath. The client's electrocardiogram (ECG) Indicates sinus tachycardia and the laboratory findings indicate an elevated serum brain natriuretic peptide (BNP) level. Which action is most important for the nurse to implement?
- A. Insert an indwelling urinary catheter.
- B. Obtain blood for serum cardiac enzymes.
- C. Provide emotional support.
- D. Auscultate lung fields for fine rales.
Correct Answer: D
Rationale: Auscultating for rales assesses for pulmonary congestion, indicated by elevated BNP and symptoms, prioritizing over catheter insertion or emotional support.
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The nurse assesses an adult client 24 hours following abdominal surgery and finds the client's blood pressure is 98/40 mm Hg. The client is tachycardiac, restless, and irritable. Which action should the nurse perform first?
- A. Ensure the IV solution is infusing at the prescribed rate.
- B. Listen to lung sounds.
- C. Notify the healthcare provider of the findings.
- D. Check under the back for evidence of bleeding.
Correct Answer: D
Rationale: Checking for bleeding addresses potential hypovolemic shock, indicated by low blood pressure and tachycardia, prioritizing over IV rate or notification.
The nurse is developing a teaching handout for female clients who return to the clinic for recurring urinary tract infections (UTI). Which client has the greatest risk for developing a UTI?
- A. An adolescent who drinks a minimum of four diet drinks daily.
- B. A client who is too busy at work to void when the urge occurs.
- C. A multipara who had pyelonephritis during her last pregnancy.
- D. An older adult who is usually incontinent of urine during the night
Correct Answer: C
Rationale: A history of pyelonephritis increases UTI risk due to prior severe urinary infection, unlike dietary habits or incontinence.
A client with coronary artery disease is hospitalized with unstable angina. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care?
- A. Encourage active range of motion exercises.
- B. Assist with ambulation in the hallway.
- C. Provide a bedside commode for toileting.
- D. Teach to sleep in a side lying position.
Correct Answer: C
Rationale: A bedside commode minimizes physical exertion, reducing cardiac workload in unstable angina.
The client's laboratory results indicate that the serum potassium level is 2.5 mEq/L (2.5 mmol/L). Which action should the nurse take?
- A. Prepare to administer a glucose, then insulin, then potassium infusion.
- B. Inform the healthcare provider of the need for potassium replacement.
- C. Instruct the client to Increase dally Intake of potassium rich foods.
- D. Change the plan of care to Include hourly urinary output measurements.
Correct Answer: B
Rationale: Severe hypokalemia requires immediate potassium replacement, necessitating healthcare provider notification, rather than dietary changes or monitoring alone.
The nurse includes the problem of 'Risk for infection' in the plan of care for a client with myelosuppression. Which laboratory value of care provides the greatest support for this nursing problem?
- A. Hematocrit of 33% (0.33 volume fraction).
- B. White blood cell count of 1,500/mm3 (1.5 x 10°)
- C. Hemoglobin of 10 g/dl (6.21 mmol/L)
- D. Red blood cell count of 3.5 x 10l(3.5 x 10°).
Correct Answer: B
Rationale: A low white blood cell count (1,500/mm³) indicates leukopenia, increasing infection risk, unlike other values.