Nokea
A client reports to the clinic nurse of recently experiencing symptoms of frequent urination, hunger, and great thirst. What finding(s) would the nurse consider as most significant to report to the healthcare provider? Select all that apply.
- A. Total cholesterol 180 mg/dL (4.7 mmol/L).
- B. Hematocrit 45% (0.45 volume fraction).
- C. Random plasma glucose level 200 mg/dL (11.1 mmol/L).
- D. Hemoglobin A1C 7%.
- E. Serum potassium of 4.2 mEq/L (4.2 mmol/L).
Correct Answer: C,D
Rationale: Elevated glucose and HbA1C indicate diabetes, correlating with the client's symptoms and requiring urgent management.
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The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?
- A. Remain upright following meals.
- B. Avoid wearing tight fitting clothes.
- C. Minimize intake of spicy foods.
- D. Begin a smoking cessation program.
Correct Answer: A
Rationale: Remaining upright prevents gastric reflux by aiding stomach emptying, directly addressing GERD symptoms.
The nurse is caring for a client after a coronary artery bypass graft surgery. The client is exhibiting pitting edema of the lower extremities and jugular venous distention with increased central venous pressure. Which condition should the nurse suspect the client is experiencing based on these findings?
- A. Right-sided heart failure.
- B. Left ventricular dysfunction.
- C. Cardiac tamponade.
- D. Internal bleeding.
Correct Answer: A
Rationale: Right-sided heart failure causes systemic venous congestion, leading to edema, jugular distention, and elevated central venous pressure.
A client is diagnosed with chronic kidney disease and needs to begin dialysis. Which condition entered on the client's medical record should the nurse recognize as a contraindication for peritoneal dialysis?
- A. Latent hepatitis C.
- B. Nephrotic syndrome history.
- C. Type 2 diabetes mellitus.
- D. Crohn's disease with colectomy.
Correct Answer: D
Rationale: Crohn's with colectomy contraindicates peritoneal dialysis due to altered abdominal anatomy, increasing infection risk.
The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?
- A. Do your family members share combs and brushes?
- B. Do you have any dry patches on your feet and hands?
- C. Has everyone at home already had varicella?
- D. Have the antifungal creams been effective?
Correct Answer: C
Rationale: Asking about varicella history assesses the risk of chickenpox transmission to susceptible household members from herpes zoster.
The nurse is caring for a client who reports a sudden, severe headache, and facial numbness. The nurse asks the client to smile and observes an uneven smile with facial droop to the right side and a hand grasp strength that is weaker on the right than the left. The client denies a recent history of headaches or trauma. Which intervention should the nurse perform in the immediate management of the client?
- A. Verify prescribed laboratory tests include prothrombin time and platelet count.
- B. Administer aspirin to prevent further clot formation and platelet clumping.
- C. Maintain elevated positioning of the dependent joints on affected side.
- D. Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.
Correct Answer: D
Rationale: IV catheters and fibrinolytic criteria review are critical for potential thrombolytic therapy in suspected ischemic stroke.