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A client recovering from cardiac surgery experiences a dysrhythmia, noted on the telemetry monitor. Which assessment finding is most likely to have contributed to the development of the dysrhythmia?
- A. Calcium level 7.2 mg/dL (1.8 mmol/L).
- B. Potassium level 3.8 mg/dl. (3.8 mmol)
- C. Sodium level 140 mEq/L (140mmol/L).
- D. Oxygen saturation level 97%.
Correct Answer: A
Rationale: Hypocalcemia (low calcium) can cause cardiac dysrhythmias, such as prolonged QT intervals, unlike normal potassium, sodium, or oxygen levels.
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A middle-aged client reports a sudden onset of seeing flashing lights and floating spots. Which is the best nursing action?
- A. Initiate a referral for ophthalmic evaluation as soon as possible.
- B. Advise the client to maintain normal activities, but avoid contact sports until the spots resolve
- C. Instruct the client to rest, and report to the emergency department if eye pain develops.
- D. Tell the client to apply warm, moist compresses and notify the healthcare provider if there is no improvement.
Correct Answer: A
Rationale: Flashing lights and floaters suggest retinal detachment, requiring urgent ophthalmic evaluation.
While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?
- A. Neutrophil count.
- B. C-reactive protein level.
- C. Platelet count.
- D. Serum potassium and sodium levels.
Correct Answer: B
Rationale: C-reactive protein (CRP) is a sensitive marker of inflammation, which often accompanies worsening wound size. Neutrophils indicate acute infection, platelets relate to clotting, and electrolytes are not directly related to wound healing.
The nurse is evaluating the effectiveness of the incentive spirometer implemented in the client's plan of care. Which outcome statement best describes the effectiveness of the incentive spirometer?
- A. Client's breath sounds are clear to auscultation bilaterally.
- B. Client exhibits a frequent productive cough.
- C. Client demonstrates proper use of an incentive spirometer.
- D. Client reports using the incentive spirometer every hour while awake.
Correct Answer: A
Rationale: Clear breath sounds indicate effective lung expansion, the primary goal of incentive spirometry, unlike cough, technique, or compliance.
The nurse is preparing a teaching plan for a client taking a prescribed diuretic for edema in the lower extremities. Which instruction should the nurse include in this teaching plan?
- A. Take the diuretic every day, regardless of weight loss or muscle weakness.
- B. Weigh yourself daily at the same time and report excessive weight loss.
- C. Limit fluid intake while taking the diuretic to reduce fluid retention.
- D. Stop taking the medication when the edema in the lower extremities subsides.
Correct Answer: B
Rationale: Daily weight monitoring helps evaluate diuretic effectiveness and detect complications. Continuous diuretic use despite weakness, limiting fluids, or stopping medication without consultation can lead to adverse outcomes.
A client with hyperparathyroidism reports a sudden onset of severe flank pain. Which intervention should the nurse include in the client's plan of care?
- A. Implement seizure precautions.
- B. Begin straining all urine.
- C. Administer a PRN dose of a laxative.
- D. Initiate cardiac telemetry.
Correct Answer: B
Rationale: Straining urine checks for kidney stones, likely causing flank pain in hyperparathyroidism, prioritizing over other interventions.