Nokea
A client receiving amlodipine (Norvasc), a calcium channel blocker, develops 1+ pitting edema around the ankles. It is most important for the nurse to obtain what additional client data?
- A. Bladder distention
- B. Serum albumin level
- C. Abdominal girth
- D. Breath sounds
Correct Answer: D
Rationale: The correct answer is D (Breath sounds). Pitting edema is a common side effect of amlodipine due to vasodilation. It can also lead to pulmonary edema, causing shortness of breath and crackles on auscultation. Therefore, assessing breath sounds is crucial to detect any signs of fluid overload and potential pulmonary complications. Bladder distention (A) is not directly related to the client's current symptoms. Serum albumin level (B) may indicate protein status but is not immediately necessary in this case. Abdominal girth (C) is more indicative of ascites or abdominal distension, not directly related to the client's edema and possible pulmonary complications.
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The nurse is evaluating the health status of an older client. Which finding is most important for the nurse to report to the healthcare provider?
- A. Client reports decreased urine output
- B. Client reports loss of appetite
- C. Client reports pain in the lower back
- D. Client reports a persistent cough
Correct Answer: C
Rationale: The correct answer is C because pain in the lower back may indicate a potential serious issue such as kidney problems or infection in the elderly. The kidneys are located in the lower back region, so pain in this area could be a sign of kidney dysfunction. The nurse should report this finding to the healthcare provider immediately for further evaluation and intervention.
Choice A is incorrect because decreased urine output can be a common issue in older adults and may not always indicate a serious problem. Choice B is incorrect as loss of appetite can have various causes and may not be as urgent as lower back pain. Choice D is also incorrect as a persistent cough can have multiple causes, but it is not as concerning as potential kidney issues indicated by lower back pain in an older client.
A college student who is diagnosed with a vaginal infection and vulva irritation describes the vaginal discharge as having a 'cottage cheese' appearance. Which prescription should the nurse implement first?
- A. Cleanse the perineum with warm soapy water 3 times per day
- B. Instill the first dose of nystatin (Mycostatin) vaginally per applicator
- C. Perform a glucose measurement using a capillary blood sample
- D. Obtain a blood specimen for sexually transmitted diseases (STDs)
Correct Answer: B
Rationale: The correct answer is B: Instill the first dose of nystatin (Mycostatin) vaginally per applicator. This is the appropriate action for a college student with symptoms of a vaginal infection with a 'cottage cheese' appearance discharge, which is indicative of a yeast infection (most likely caused by Candida). Nystatin is an antifungal medication effective against Candida, hence addressing the root cause of the infection. It is essential to start with the treatment first to alleviate the symptoms and prevent further complications.
Incorrect choices:
A: Cleansing the perineum with warm soapy water may provide some comfort but does not address the underlying infection.
C: Performing a glucose measurement is not necessary at this stage as the symptoms suggest a yeast infection, not diabetes.
D: Obtaining a blood specimen for STDs is not the priority in this case as the symptoms are indicative of a yeast infection, not an STD.
The nurse is administering total parenteral nutrition (TPN) via a central line at 75 ml/hour to a client who had a bowel resection 4 days ago. Which laboratory finding requires the most immediate intervention by the nurse?
- A. Blood glucose of 140 mg/dL
- B. White blood cell count of 8000/mm³
- C. Serum potassium of 3.8 mEq/L
- D. Serum calcium of 7.8 mg/dL
Correct Answer: D
Rationale: The correct answer is D: Serum calcium of 7.8 mg/dL. This finding indicates hypocalcemia, which can lead to life-threatening cardiac arrhythmias. Low calcium levels can be caused by TPN administration or poor calcium absorption following bowel resection. Immediate intervention may include administering IV calcium gluconate.
A: Blood glucose of 140 mg/dL is within the normal range and not an immediate concern.
B: White blood cell count of 8000/mm³ is within the normal range and does not require immediate intervention.
C: Serum potassium of 3.8 mEq/L is within the normal range and does not pose an immediate threat.
The nurse is caring for a laboring 22-year-old primigravida following administration of regional anesthesia. In planning care for this client, what nursing intervention has the highest priority?
- A. Raising the side rails and placing the call bell within reach
- B. Teaching the client how to push effectively to decrease the length of the second stage of labor
- C. Timing and recording uterine contractions
- D. Positioning the client for proper distribution of anesthesia
Correct Answer: A
Rationale: The correct answer is A because raising the side rails and placing the call bell within reach ensures the safety and immediate accessibility of the client, which is the highest priority in nursing care. This intervention helps prevent falls or other accidents and allows the client to call for assistance if needed.
Choice B is incorrect because teaching pushing techniques is important but not the highest priority at this moment. Choice C, timing and recording uterine contractions, is also important but not the highest priority compared to ensuring the client's safety. Choice D, positioning for anesthesia distribution, is relevant but not as critical as ensuring immediate access to assistance in case of emergency.
An angry client screams at the emergency department triage nurse, 'I've been waiting here for two hours! You and the staff are incompetent.' What is the best response for the nurse to make?
- A. The emergency department is very busy at this time.
- B. I'll let you see the doctor next because you've waited so long.
- C. I'm doing the best I can for the sickest clients first.
- D. I understand you are frustrated with the wait time.
Correct Answer: D
Rationale: The correct answer is D because it demonstrates empathy and acknowledges the client's feelings without admitting fault. By saying "I understand you are frustrated with the wait time," the nurse validates the client's emotions and shows a willingness to listen and address concerns. This response can help de-escalate the situation and build rapport.
Choice A is incorrect because it doesn't directly address the client's emotions. Choice B is incorrect as it prioritizes the client based on their anger rather than medical need. Choice C is incorrect as it may come off as dismissive of the client's feelings and lacks empathy.