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A client with a diagnosis of heart failure is receiving furosemide (Lasix). Which electrolyte imbalance should the nurse monitor for?
- A. Hyperkalemia.
- B. Hyponatremia.
- C. Hypocalcemia.
- D. Hypokalemia.
Correct Answer: D
Rationale: The correct answer is D: Hypokalemia. Furosemide is a loop diuretic that can cause potassium loss, leading to hypokalemia. Therefore, the nurse should monitor the client for low potassium levels. Choice A, Hyperkalemia, is incorrect as furosemide does not typically cause high potassium levels. Choice B, Hyponatremia, is incorrect as furosemide primarily affects potassium levels, not sodium. Choice C, Hypocalcemia, is incorrect as furosemide does not directly impact calcium levels.
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A client with chronic obstructive pulmonary disease (COPD) is struggling to breathe. What should the nurse do first?
- A. Increase the oxygen flow rate according to the prescription
- B. Encourage the client to perform pursed-lip breathing
- C. Prepare for emergency intubation
- D. Assess the client's oxygen saturation and breath sounds
Correct Answer: D
Rationale: The correct first action for a nurse when a client with COPD is struggling to breathe is to assess the client's oxygen saturation and breath sounds. This initial assessment is crucial in determining the severity of the client's condition and the appropriate intervention. Increasing the oxygen flow rate without proper assessment can potentially be harmful, as COPD clients have a risk of retaining carbon dioxide. Encouraging pursed-lip breathing can be beneficial but should come after assessing the client's current status. Emergency intubation is a drastic measure and should only be considered after a comprehensive assessment indicates the need for it.
The nurse is caring for a client with an intravenous infusion of normal saline. The client reports pain and swelling at the IV site. What is the nurse's priority action?
- A. Slow the rate of infusion
- B. Apply a warm compress to the site
- C. Discontinue the IV infusion
- D. Elevate the affected arm
Correct Answer: C
Rationale: The correct answer is to discontinue the IV infusion (Choice C). Pain and swelling at the IV site can indicate infiltration or phlebitis, which are serious complications that require immediate action. Slowing the rate of infusion (Choice A) may not address the underlying issue and can potentially worsen the condition. Applying a warm compress (Choice B) may provide temporary relief but does not address the need to discontinue the infusion. Elevating the affected arm (Choice D) is not the priority in this situation; discontinuing the infusion takes precedence to prevent further harm.
The healthcare provider reviews the laboratory results of a client whose serum pH is 7.38. What does this value imply about the client's homeostasis?
- A. Alkalosis
- B. Acidosis
- C. Normal serum pH
- D. Incompatible with life
Correct Answer: C
Rationale: A pH of 7.38 falls within the normal range (7.35-7.45), indicating that the client's acid-base balance is adequately maintained. Choices A and B are incorrect as alkalosis and acidosis refer to abnormal pH levels. Choice D is incorrect as a pH of 7.38 within the normal range is compatible with life.
The client with a new colostomy is being taught about colostomy care. Which statement by the client indicates effective learning?
- A. I will change my colostomy bag every day.
- B. I should eat a low-fiber diet.
- C. I need to inspect the stoma daily for color and swelling.
- D. I can skip my colostomy care if I feel well.
Correct Answer: C
Rationale: The correct answer is C because inspecting the stoma daily is crucial in identifying any early signs of complications or infections. Choice A is incorrect because changing the colostomy bag daily is not necessary unless there is a specific reason to do so. Choice B is incorrect as a low-fiber diet is not usually recommended for colostomy care. Choice D is incorrect because colostomy care should be performed regularly regardless of how the client feels.
The nurse is caring for a client with a diagnosis of major depressive disorder who has been prescribed a selective serotonin reuptake inhibitor (SSRI). What is the most important teaching point?
- A. Take the medication with food.
- B. Expect to see improvement within 24 hours.
- C. Avoid drinking grapefruit juice.
- D. Report any thoughts of self-harm immediately.
Correct Answer: D
Rationale: The correct answer is D: 'Report any thoughts of self-harm immediately.' Clients prescribed SSRIs should be educated to report any thoughts of self-harm promptly, as these medications can initially increase suicidal ideation. Choice A is incorrect because SSRIs are usually taken on an empty stomach. Choice B is incorrect as it takes several weeks for SSRIs to reach their full effectiveness. Choice C is irrelevant to SSRI therapy.