Nokea
A client who received multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse's decision to hold the client's scheduled antihypertensive medication?
- A. Increased urinary clearance of the multiple medications has produced diuresis and lowered the blood pressure
- B. The antagonistic interaction among the various blood pressure medications has reduced their effectiveness
- C. The additive effect of multiple medications has caused the blood pressure to drop too low.
- D. The synergistic effect of the multiple medications has resulted in drug toxicity and resulting hypotension.
Correct Answer: C
Rationale: When medications with a similar action are administered, an additive effect occurs that is the sum of the effects of each medication. In this case, several medications that all lower blood pressure, when administered together, resulted in hypotension.
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The nurse is caring for a client with diabetic ketoacidosis (DKA). Which laboratory value requires immediate intervention?
- A. Serum glucose of 300 mg/dL
- B. Serum potassium of 4.5 mEq/L
- C. Serum bicarbonate of 15 mEq/L
- D. Serum pH of 7.28
Correct Answer: D
Rationale: A serum pH of 7.28 indicates metabolic acidosis in a client with diabetic ketoacidosis (DKA), requiring immediate intervention. In DKA, the body produces excess ketones, leading to acidosis. Monitoring and correcting the pH level is crucial in managing DKA. Serum glucose levels may be high in DKA, but the immediate concern is correcting the acidosis to prevent complications. Serum potassium and bicarbonate levels are also important but not as immediately critical as correcting the acidosis in DKA.
The nurse reviews the laboratory findings of a client with an open fracture of the tibia. The white blood cell (WBC) count and erythrocyte sedimentation rate (ESR) are elevated. Before reporting this information to the healthcare provider, what assessment should the nurse obtain?
- A. Appearance of wound
- B. Pain level
- C. Presence of fever
- D. Mobility status
Correct Answer: A
Rationale: The correct answer is A: Appearance of wound. Elevated WBC and ESR levels suggest a possible infection in the client with an open fracture. Assessing the wound's appearance is crucial to evaluate for signs of infection, such as redness, warmth, swelling, or drainage. By assessing the wound first, the nurse can provide important information to the healthcare provider regarding the potential infection, which may require immediate intervention. Choices B, C, and D are important assessments in caring for a client with an open fracture; however, in this scenario, the priority is to assess the wound for signs of infection due to the elevated WBC and ESR levels.
While performing a skin inspection for a female adult client, the nurse observes a rash that is well circumscribed, has silvery scales and plaques, and is located on the elbows and knees. These assessment findings are likely to indicate which condition?
- A. Tinea corporis
- B. Herpes zoster
- C. Psoriasis
- D. Drug reaction
Correct Answer: C
Rationale: The correct answer is C, Psoriasis. Psoriasis commonly presents with well-circumscribed, silvery scales and plaques, typically found on extensor surfaces like elbows and knees. Tinea corporis (A) presents as a circular rash, herpes zoster (B) presents as a painful rash following a dermatomal pattern, and drug reactions (D) have variable presentations not specific to elbows and knees with silvery scales and plaques.
The nurse is reinforcing home care instructions with a client who is being discharged following a transurethral resection of the prostate (TURP). Which intervention is most important for the nurse to include in the client teaching?
- A. Avoid strenuous activity for 6 weeks.
- B. Report fresh blood in the urine.
- C. Take acetaminophen for a fever over 101°F.
- D. Consume 6 to 8 glasses of water daily.
Correct Answer: B
Rationale: Reporting fresh blood in the urine is crucial as it may indicate postoperative complications requiring immediate attention. This symptom can be a sign of bleeding, infection, or other issues that need prompt medical evaluation. Avoiding strenuous activity for 6 weeks is important but not as urgent as reporting fresh blood. Taking acetaminophen for a fever over 101°F is relevant but addressing fresh blood in the urine takes precedence. Consuming an adequate amount of water daily is beneficial but not as critical as recognizing and reporting signs of potential complications.
The nurse is caring for a client with a chest tube following a pneumothorax. Which finding requires immediate intervention?
- A. Oxygen saturation of 94%
- B. Crepitus around the insertion site
- C. Subcutaneous emphysema
- D. Drainage of 50 ml per hour
Correct Answer: C
Rationale: Subcutaneous emphysema is the most critical finding requiring immediate intervention in a client with a chest tube following a pneumothorax. It may indicate a pneumothorax recurrence or air leak, which can lead to respiratory compromise. Oxygen saturation of 94% is slightly low but may not require immediate intervention. Crepitus around the insertion site can be a normal finding post-procedure. Drainage of 50 ml per hour is within the expected range for a chest tube output and does not indicate an immediate concern.