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A client is receiving opioid analgesics for pain management. Which of the following assessments is the priority?
- A. Monitor the client's blood pressure.
- B. Check the client's urinary output.
- C. Monitor the client's respiratory rate.
- D. Assess the client's pain level.
Correct Answer: C
Rationale: The correct answer is C: Monitor the client's respiratory rate. When a client is receiving opioid analgesics, the priority assessment is monitoring respiratory rate. Opioids can cause respiratory depression, so it is crucial to assess the client's breathing to detect any signs of respiratory distress promptly. Checking the client's blood pressure (Choice A) and urinary output (Choice B) are important assessments too, but they are not the priority when compared to ensuring adequate respiratory function. Assessing the client's pain level (Choice D) is essential for overall care but is not the priority assessment when the client is on opioids, as respiratory status takes precedence.
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How should a healthcare professional manage a patient with fluid overload in heart failure?
- A. Monitor daily weight
- B. Check for edema
- C. Monitor intake and output
- D. Administer diuretics
Correct Answer: A
Rationale: Monitoring daily weight is crucial in managing a patient with fluid overload in heart failure. Weight fluctuations can indicate fluid retention or loss, guiding healthcare professionals in adjusting treatment. While checking for edema (Choice B) and monitoring intake and output (Choice C) are important aspects of patient care, they are not as direct in assessing fluid overload as daily weight monitoring. Administering diuretics (Choice D) is a treatment option based on the assessment of fluid overload, making it a secondary intervention compared to monitoring weight.
Which lab value is critical for a patient on heparin therapy?
- A. Monitor aPTT
- B. Monitor INR
- C. Monitor platelet count
- D. Monitor sodium levels
Correct Answer: A
Rationale: The correct answer is to monitor aPTT. Activated Partial Thromboplastin Time (aPTT) is crucial for patients on heparin therapy as it helps determine the clotting ability of the blood. By monitoring aPTT, healthcare providers can adjust the dosage of heparin to maintain therapeutic levels and prevent bleeding complications. Monitoring INR is more commonly associated with warfarin therapy, not heparin. Monitoring platelet count is important for assessing the risk of bleeding or clotting disorders but is not specific to heparin therapy. Monitoring sodium levels is not directly related to assessing the effectiveness or safety of heparin therapy.
A nurse is caring for a client with deep vein thrombosis who is prescribed warfarin. Which of the following client statements indicates a need for further teaching?
- A. I will avoid vitamin K-rich foods.
- B. I will avoid using aspirin while on this medication.
- C. I will monitor my blood pressure regularly.
- D. I will increase my intake of leafy greens.
Correct Answer: D
Rationale: The correct answer is D. Warfarin's effectiveness is reduced by high intake of vitamin K-rich foods, so increasing their intake would contradict the treatment plan. Choices A, B, and C are all appropriate statements for a client on warfarin therapy. Avoiding vitamin K-rich foods helps maintain the medication's effectiveness, avoiding aspirin reduces the risk of bleeding, and monitoring blood pressure is essential for overall health monitoring.
A client with heart failure is being assessed by a nurse. Which of the following findings indicates the client is experiencing fluid overload?
- A. Dry, hacking cough
- B. Bounding peripheral pulses
- C. Decreased urinary output
- D. Weight loss of 1 kg in 24 hours
Correct Answer: C
Rationale: In clients with heart failure, decreased urinary output is a classic sign of fluid overload. The kidneys try to compensate for the increased volume by reducing urine output, leading to fluid retention. A dry, hacking cough (choice A) is more indicative of heart failure complications like pulmonary edema. Bounding peripheral pulses (choice B) are a sign of increased volume, but not specifically fluid overload. Weight loss of 1 kg in 24 hours (choice D) is not indicative of fluid overload but rather rapid fluid loss.
A nurse is providing discharge teaching to a client who has a new diagnosis of diabetes mellitus. Which of the following client statements indicates a need for further teaching?
- A. I will check my blood glucose level once a week.
- B. I will eat a snack if my blood glucose level is above 200 mg/dL.
- C. I will take my insulin as prescribed, even when I am feeling well.
- D. I will avoid physical activity if my blood glucose level is below 100 mg/dL.
Correct Answer: B
Rationale: The correct answer is B. Clients should eat a snack when their blood glucose level is low, typically below 70-100 mg/dL, not when it is high. Eating a snack when the blood glucose level is above 200 mg/dL can exacerbate hyperglycemia. Choice A is correct as checking blood glucose levels regularly is important in managing diabetes. Choice C is also correct as adherence to prescribed insulin therapy is crucial. Choice D is incorrect as physical activity can help lower blood glucose levels, especially when they are above the target range.