Nokea
A client is admitted with a diagnosis of pneumonia and is receiving IV antibiotics. Which assessment finding indicates that the treatment is effective?
- A. Client reports less chest pain.
- B. Client's white blood cell count is decreasing.
- C. Client has a decreased respiratory rate.
- D. Client has clear breath sounds.
Correct Answer: D
Rationale: The correct answer is D. Clear breath sounds indicate that the pneumonia is resolving and the treatment is effective. Breath sounds are often muffled or crackling in pneumonia due to the presence of fluid or inflammation in the lungs. Clear breath sounds suggest that the air is moving freely through the lungs, indicating improvement. Choices A, B, and C are less specific indicators of pneumonia resolution. While less chest pain and a decreasing white blood cell count can be positive signs, they are not as direct in indicating the effectiveness of pneumonia treatment as the presence of clear breath sounds. A decreased respiratory rate could be seen in various conditions and may not solely indicate the resolution of pneumonia.
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The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days. What assessment is most important for the nurse to complete?
- A. Auscultate the client's bowel sounds
- B. Observe for edema around the ankles
- C. Measure the client's capillary glucose level
- D. Count the apical and radial pulses simultaneously
Correct Answer: A
Rationale: The correct answer is to auscultate the client's bowel sounds. Hydromorphone is a potent opioid analgesic that can slow peristalsis and commonly cause constipation. By assessing the client's bowel sounds, the nurse can monitor for any signs of decreased bowel motility or potential constipation. Observing for edema (Choice B) is not directly related to hydromorphone administration. Measuring capillary glucose levels (Choice C) is not the priority in this situation. Counting the apical and radial pulses simultaneously (Choice D) is not specifically indicated in this scenario involving hydromorphone administration.
Which nursing intervention has the highest priority for a multigravida who delivered twins and is at risk for postpartum hemorrhage?
- A. Maintain cold packs on the perineum for 24 hours.
- B. Assess the client's pain level frequently.
- C. Observe for appropriate interaction with the infants.
- D. Assess fundal tone and lochia flow.
Correct Answer: D
Rationale: Assessing fundal tone and lochia flow is crucial in the early detection and prevention of postpartum hemorrhage. Fundal tone helps identify uterine atony, a common cause of postpartum hemorrhage, while monitoring lochia flow can indicate excessive bleeding. Cold packs on the perineum, although helpful for pain and swelling, are not the priority in this situation. Pain assessment and observing interactions with infants are important but secondary to assessing for signs of postpartum hemorrhage.
The nurse is reinforcing home care instructions with a client who is being discharged following a transurethral resection of the prostate (TURP). Which intervention is most important for the nurse to include in the client teaching?
- A. Avoid strenuous activity for 6 weeks.
- B. Report fresh blood in the urine.
- C. Take acetaminophen for a fever over 101°F.
- D. Consume 6 to 8 glasses of water daily.
Correct Answer: B
Rationale: Reporting fresh blood in the urine is crucial as it may indicate postoperative complications requiring immediate attention. This symptom can be a sign of bleeding, infection, or other issues that need prompt medical evaluation. Avoiding strenuous activity for 6 weeks is important but not as urgent as reporting fresh blood. Taking acetaminophen for a fever over 101°F is relevant but addressing fresh blood in the urine takes precedence. Consuming an adequate amount of water daily is beneficial but not as critical as recognizing and reporting signs of potential complications.
In a client with liver cirrhosis admitted with ascites and jaundice, which laboratory value is most concerning to the nurse?
- A. Serum albumin of 3.0 g/dl
- B. Bilirubin of 3.0 mg/dl
- C. Ammonia level of 80 mcg/dl
- D. Prothrombin time of 18 seconds
Correct Answer: C
Rationale: An elevated ammonia level of 80 mcg/dl is most concerning in a client with liver cirrhosis because it may indicate hepatic encephalopathy, a serious complication. Serum albumin, though low, is expected in cirrhosis and contributes to ascites. Bilirubin elevation is common in liver disease but may not be the most concerning in this case. Prothrombin time is typically prolonged in liver disease but may not be as acute as an elevated ammonia level suggesting hepatic encephalopathy.
The nurse is administering an IV medication to a client with a history of anaphylaxis. Which intervention is most important for the nurse to implement?
- A. Stay with the client throughout the infusion.
- B. Keep emergency resuscitation equipment at the bedside.
- C. Obtain the client's allergy history.
- D. Ask the client about past allergic reactions to medications.
Correct Answer: B
Rationale: Keeping emergency resuscitation equipment at the bedside is crucial in case the client experiences anaphylaxis during the infusion. While staying with the client throughout the infusion (Choice A) is important, having immediate access to emergency equipment takes priority in this situation. Obtaining the client's allergy history (Choice C) and asking about past allergic reactions to medications (Choice D) are relevant but do not address the immediate need for emergency intervention in case of anaphylaxis.