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A client is admitted to the hospital with a serum sodium level of 128 mEq/L, distended neck veins, and lung crackles. What intervention should the nurse implement?
- A. Increase the intake of salty foods
- B. Administer NaCl supplements
- C. Restrict oral fluid intake
- D. Hold the client's loop diuretic
Correct Answer: C
Rationale: In the scenario described, the client presents with signs of fluid overload and hyponatremia. Restricting oral fluid intake is the appropriate intervention to manage fluid overload and correct hyponatremia. Increasing the intake of salty foods (Choice A) and administering NaCl supplements (Choice B) would exacerbate the sodium imbalance. Holding the client's loop diuretic (Choice D) is not directly related to addressing the fluid overload and hyponatremia.
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What instruction should the nurse provide a pregnant client experiencing heartburn?
- A. Limit fluid intake between meals to prevent stomach over-distension
- B. Take an antacid at bedtime and when symptoms worsen
- C. Maintain an upright position for two hours after eating
- D. Eat small meals throughout the day to avoid a full stomach
Correct Answer: D
Rationale: The correct answer is D: 'Eat small meals throughout the day to avoid a full stomach.' Heartburn is common in pregnancy due to increased intra-abdominal pressure and hormonal changes. Consuming small, frequent meals prevents the stomach from becoming overly full, reducing the likelihood of acid reflux and heartburn. Choice A is incorrect because limiting fluid intake between meals may not significantly impact heartburn. Choice B is not ideal as antacids should be taken as directed by a healthcare provider, not just at bedtime or when symptoms worsen. Choice C is less effective advice, as maintaining an upright position after eating may not directly address the root cause of heartburn.
Identify the placement of the stapes footplate into the bony labyrinth.
- A. Fenestra vestibuli
- B. Fenestra cochleae
- C. Tympanic membrane
- D. Round window
Correct Answer: A
Rationale: The correct answer is A: Fenestra vestibuli. The stapes footplate is placed into the fenestra vestibuli of the bony labyrinth. This structure is also known as the oval window and is located at the junction of the middle ear and inner ear. Choice B, Fenestra cochleae, is incorrect as this opening is also known as the round window and is located near the base of the cochlea. Choice C, Tympanic membrane, is incorrect as it is also known as the eardrum and separates the external ear from the middle ear. Choice D, Round window, is incorrect as it is the opening covered by the secondary tympanic membrane and is important for the dissipation of sound waves in the cochlea.
A high school football player comes to the clinic complaining of severe acne. The mother reports recent behavior changes, including irritability and suspiciousness of friends. The nurse's assessment reveals an elevated blood pressure. Which intervention should the nurse implement first?
- A. Encourage the client to see a dermatologist
- B. Refer the adolescent to a substance abuse program
- C. Suggest a low-salt, low-fat, and caffeine-free diet
- D. Inquire about a possible use of anabolic steroids
Correct Answer: D
Rationale: In this scenario, the high school football player presenting with severe acne, behavior changes, elevated blood pressure, and suspicion of friends suggests the possible use of anabolic steroids. Anabolic steroid use can lead to such symptoms. Therefore, the nurse should first inquire about the possible use of anabolic steroids to address the root cause of the presenting issues. Encouraging the client to see a dermatologist (Choice A) may be necessary but addressing the underlying cause is crucial first. Referring the adolescent to a substance abuse program (Choice B) is premature without confirming steroid use. Suggesting a low-salt, low-fat, and caffeine-free diet (Choice C) is not the priority in this situation where a serious issue like anabolic steroid use needs immediate attention.
A client with osteoporosis related to long-term corticosteroid therapy receives a prescription for calcium carbonate. Which client's serum laboratory value requires intervention by the nurse?
- A. Total calcium 9 mg/dl (2.25 mmol/L SI)
- B. Creatinine 4 mg/dl (354 micromol/L SI)
- C. Phosphate 4 mg/dl (1.293 mmol/L SI)
- D. Fasting glucose 95 mg/dl (5.3 mmol/L SI)
Correct Answer: B
Rationale: An elevated creatinine level indicates possible renal impairment, which requires intervention. High creatinine levels are associated with decreased kidney function, and in this case, it suggests potential renal issues due to long-term corticosteroid therapy. Monitoring renal function is crucial in clients with osteoporosis on corticosteroid therapy to prevent further complications. Total calcium levels within the normal range are suitable for a client with osteoporosis receiving calcium carbonate. Phosphate and fasting glucose levels do not directly indicate renal impairment in this scenario.
The nurse receives change of shift report on a group of clients for the upcoming shift. A client with which condition requires the most immediate attention by the nurse?
- A. Gunshot wound three hours ago with dark drainage of 2 cm on the dressing
- B. Mastectomy 2 days ago with 50 ml bloody drainage in the Jackson-Pratt drain
- C. Collapsed lung after a fall 8 hours ago with 100 ml blood in the chest tube collection container
- D. Abdominal-perineal resection 2 days ago with no drainage on dressing and fever and chills
Correct Answer: C
Rationale: A collapsed lung with significant blood accumulation requires immediate attention to prevent respiratory compromise. Option A may also require attention, but the immediate threat to airway and breathing in option C takes precedence over the others. Option B has expected drainage after a mastectomy, and option D's fever and chills, while concerning, do not pose an immediate life-threatening risk as in option C.