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A client taking antibiotics for three days to treat a Streptococcal throat infection returns to the clinic reporting a feel itchy rash across the chest and arms. The nurse auscultates pulmonary wheezing and an elevated heart rate. Which action should the nurse implement?
- A. Swab the throat for a rapid strep test.
- B. Provide a mask for the client to wear.
- C. Instruct client to stop taking the antibiotics.
- D. Apply a hypoallergenic cream to the rash.
Correct Answer: C
Rationale: Symptoms like rash, wheezing, and tachycardia suggest an allergic reaction to antibiotics, requiring immediate cessation to prevent progression to severe reactions like anaphylaxis.
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An older client with cirrhosis of the liver and hepatic failure is placed on a low sodium diet and is receiving periodic albumin infusions. Which assessment finding indicates progress toward the desired effect of this treatment plan?
- A. Clear, dark amber-colored urine.
- B. Improved level of consciousness.
- C. Prothrombin time within normal limits.
- D. Decreased abdominal girth.
Correct Answer: D
Rationale: Decreased abdominal girth indicates reduced ascites, a direct result of low sodium diet and albumin infusions, which reduce fluid retention and increase oncotic pressure.
A client with metastatic cancer reports a pain level of 10 on a pain scale of 0 to 10. Twenty minutes after the nurse administers an IV analgesic, the client reports no pain relief. Which intervention is most important for the nurse to include in this client's plan of care?
- A. Administer analgesics on a fixed and continuous schedule.
- B. Frequently evaluate the client's pain.
- C. Replace transdermal analgesic patches every 72 hours.
- D. Monitor client for break-through pain.
Correct Answer: A
Rationale: A fixed and continuous analgesic schedule ensures consistent pain relief for chronic severe cancer pain, preventing fluctuations and addressing inadequate response to the initial dose.
After teaching a client newly diagnosed with cholecystitis about recommended diet changes, the nurse evaluates the client's learning. Which food choices eliminated by the client indicate to the nurse that teaching has been successful?
- A. Whole milk and daily servings of ice cream.
- B. Citrus fruit and melon with a salt substitute.
- C. Pasta with herbal butter and no meat sauce.
- D. Canned vegetables with additional table salt.
Correct Answer: A
Rationale: Eliminating whole milk and ice cream, which are high in fat, prevents gallbladder inflammation and gallstone formation, indicating successful learning about cholecystitis diet.
The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?
- A. Apical heart rate of 100 to 110 beats/minute.
- B. Redness and edema noted at the incision site.
- C. High-pitched sound heard upon inspiration.
- D. Pain rating of 8 on a scale of 1 to 10.
Correct Answer: C
Rationale: A high-pitched sound (stridor) indicates potential airway obstruction, a life-threatening emergency requiring immediate intervention to ensure airway patency.
The nurse is caring for a client with chemotherapy-induced mucositis who is describing soreness of the tongue and oral issues. Which is the best initial nursing action?
- A. Cleanse the tongue and mouth with swabs.
- B. Administer a topical analgesic per protocol.
- C. Obtain a soft diet for the client.
- D. Encourage frequent mouth care.
Correct Answer: B
Rationale: Administering a topical analgesic provides immediate pain relief for mucositis, addressing the client's discomfort first before implementing other supportive measures like diet or mouth care.