Nokea
A client is experiencing pulmonary edema as an exacerbation of chronic left-sided heart failure. The nurse should assess the client for what manifestation?
- A. Weight loss
- B. Bilateral crackles
- C. Distended neck veins
- D. Peripheral pitting edema
Correct Answer: B
Rationale: The client with pulmonary edema presents primarily with symptoms that are respiratory in nature because the blood flow is stagnant in the lungs, which lie behind the left side of the heart from a circulatory standpoint. The client would experience weight gain from fluid retention, not weight loss. Distended neck veins and peripheral pitting edema are classic signs of right-sided heart failure.
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The nurse is preparing to provide postsurgical care for a client after a subtotal thyroidectomy. The nurse anticipates the need for which item to be placed at the bedside to minimize the client's risk for injury?
- A. Hypothermia blanket
- B. Emergency tracheostomy kit
- C. Magnesium sulfate in a ready-to-inject vial
- D. Ampule of saturated solution of potassium iodide
Correct Answer: B
Rationale: Respiratory distress can occur after thyroidectomy as a result of swelling in the tracheal area. The nurse would ensure that an emergency tracheostomy kit is available. Surgery on the thyroid does not alter the heat control mechanism of the body. Magnesium sulfate would not be indicated because the incidence of hypomagnesemia is not a common problem after thyroidectomy. Saturated solution of potassium iodide is typically administered preoperatively to block thyroid hormone synthesis and release and to place the client in a euthyroid state.
A client has been prescribed procainamide. The nurse implements which intervention before administering the medication to minimize the client's risk for injury?
- A. Obtaining a chest x-ray
- B. Assessing blood pressure and pulse
- C. Obtaining a complete blood cell count and liver function studies
- D. Scheduling a drug level to be drawn 1 hour after the dose is administered
Correct Answer: B
Rationale: Procainamide is an antidysrhythmic medication. Before the medication is administered, the client's blood pressure and pulse are checked. This medication can cause toxic effects, and serum blood levels would be checked before administering the medication (therapeutic serum level is 4 to 10 mcg/mL [17.00 to 42.50 mcmol/L]). A chest x-ray and obtaining a complete blood cell count and liver function studies are unnecessary.
The nurse is conducting a health history on a client diagnosed with hyperparathyroidism. Which question asked of the client would elicit information about this condition?
- A. Do you have tremors in your hands?
- B. Are you experiencing pain in your joints?
- C. Have you had problems with diarrhea lately?
- D. Do you notice any swelling in your legs at night?
Correct Answer: B
Rationale: Hyperparathyroidism causes an oversecretion of parathyroid hormone (PTH), which causes excessive osteoblast growth and activity within the bones. When bone reabsorption is increased, calcium is released from the bones into the blood, causing hypercalcemia. The bones suffer demineralization as a result of calcium loss, leading to bone and joint pain and pathological fractures. Options 1 and 3 relate to assessment of hypoparathyroidism. Option 4 is unrelated to hyperparathyroidism.
The nurse assists a client diagnosed with a renal disorder in collecting a 24-hour urine specimen. Which intervention does the nurse implement to ensure proper collection of the 24-hour urine specimen?
- A. Have the client void at the start time and discard the specimen.
- B. Strain the specimen before pouring the urine into the container.
- C. Save all urine, beginning with the urine voided at the start time.
- D. Once completed, refrigerate the urine collection until picked up by the laboratory.
Correct Answer: A
Rationale: The nurse asks the client to void at the beginning of the collection period and discards this urine sample because this urine has been stored in the bladder for an undetermined length of time. All urine thereafter is saved in an iced or refrigerated container. The client is asked to void at the finish time, and this sample is the last specimen added to the collection.
The nurse is developing a care plan for an older client being admitted to a long-term care facility. Which information should the nurse use to plan interventions for this client? Select all that apply.
- A. Older clients tend to be incontinent.
- B. Older clients are at risk for dehydration.
- C. Depression is a normal part of the aging process.
- D. Age-related skin changes require special monitoring.
- E. Older clients are at risk for complications of immobility.
- F. Confusion and cognitive changes are common findings in the older population.
Correct Answer: B,D,E
Rationale: Older clients are at risk for dehydration and complications related to immobility. Another normal physiological change that occurs during the aging process is loss of skin integrity. Incontinence, depression, confusion, and cognitive changes are not normal parts of the aging process.