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A client with a history of angina pectoris reports chest pain after climbing stairs. What should be the nurse's first action?
- A. Administer oxygen.
- B. Administer nitroglycerin.
- C. Sit the client down and rest.
- D. Check the client's blood pressure.
Correct Answer: C
Rationale: The correct action for a client experiencing anginal pain, like chest pain after climbing stairs, is to sit the client down and have them rest. Resting reduces myocardial oxygen demand, which can help relieve anginal pain. Administering oxygen or nitroglycerin may be appropriate interventions after the client has been seated and rested. Checking the client's blood pressure is important but not the immediate priority when a client is experiencing anginal pain. Therefore, the first action should be to sit the client down and allow them to rest.
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The healthcare professional is assessing a client who presents with jaundice. Which assessment finding is most important for the healthcare professional to follow up on?
- A. Urine specific gravity of 1.03
- B. Frothy, tea-colored urine
- C. Clay-colored stools
- D. Elevated serum amylase and lipase levels
Correct Answer: D
Rationale: Elevated serum amylase and lipase levels are indicative of pancreatitis, a serious condition that can manifest with jaundice. Timely follow-up is crucial to manage pancreatitis and its complications effectively in a jaundiced client. Choices A, B, and C are less critical in this scenario. Urine specific gravity within normal range, frothy tea-colored urine, and clay-colored stools can be associated with various conditions but are not directly indicative of pancreatitis, which is the most concerning condition associated with jaundice.
What predisposing factor most likely contributed to the proximal end of the femur fracture in a 62-year-old woman who lives alone and tripped on a rug in her home?
- A. Failing eyesight leading to an unsafe environment
- B. Renal osteodystrophy from chronic kidney disease (CKD)
- C. Osteoporosis from declining hormone levels
- D. Cerebral vessel changes causing transient ischemic attacks
Correct Answer: C
Rationale: The most likely predisposing factor contributing to the proximal end of the femur fracture in a 62-year-old woman is osteoporosis resulting from declining hormone levels. Osteoporosis weakens the bones, making them more susceptible to fractures, especially in older adults, particularly women. In this case, the fracture can be attributed to the bone density loss associated with osteoporosis, which is a common concern in postmenopausal women. Choices A, B, and D are less likely to have directly contributed to the femur fracture in this scenario. Failing eyesight may increase the risk of falls but does not directly weaken the bones. Renal osteodystrophy affects bone health but is less common in this age group. Cerebral vessel changes causing transient ischemic attacks are related to vascular issues, not bone strength.
The primary care NP performs a physical examination on an 89-year-old patient who is about to enter a skilled nursing facility. The patient reports having had chickenpox as a child. The NP should:
- A. obtain a varicella titer.
- B. administer the Varivax vaccine.
- C. give the patient the Zostavax vaccine.
- D. plan to prescribe Zovirax if the patient is exposed to shingles.
Correct Answer: C
Rationale: The correct answer is C because Zostavax is recommended for adults over 60 to prevent shingles, regardless of prior chickenpox. Choice A is incorrect (titer not needed). Choice B is wrong (Varivax not for shingles). Choice D is inaccurate (prophylaxis not standard).
The client has been prescribed atorvastatin (Lipitor) for hyperlipidemia. Which instruction should the nurse provide to the client?
- A. Take the medication in the morning with breakfast.
- B. Avoid drinking grapefruit juice while taking this medication.
- C. Increase your intake of dietary fiber while on this medication.
- D. Avoid eating foods high in potassium.
Correct Answer: B
Rationale: The correct instruction for the nurse to provide to the client prescribed atorvastatin (Lipitor) for hyperlipidemia is to avoid drinking grapefruit juice while taking this medication. Grapefruit juice can interfere with the metabolism of atorvastatin, leading to an increased risk of side effects. It is crucial for the client to adhere to this instruction to ensure the effectiveness and safety of the treatment. Choices A, C, and D are incorrect because taking the medication with breakfast, increasing dietary fiber intake, and avoiding foods high in potassium are not specific instructions related to atorvastatin therapy for hyperlipidemia.
An 81-year-old male client has emphysema. He lives at home with his cat and manages self-care with no difficulty. When making a home visit, the nurse notices that this client's tongue is somewhat cracked, and his eyeballs appear sunken into his head. Which nursing intervention is indicated?
- A. Help the client determine ways to increase his fluid intake.
- B. Obtain an appointment for the client to have an eye examination.
- C. Instruct the client to use oxygen at night and increase humidification.
- D. Schedule the client for tests to determine his sensitivity to cat hair.
Correct Answer: A
Rationale: The client's cracked tongue and sunken eyes indicate dehydration. Therefore, the priority nursing intervention is to help the client determine ways to increase his fluid intake. Dehydration can exacerbate the client's emphysema symptoms and lead to further complications. Monitoring and addressing the client's fluid intake is crucial for maintaining his health and well-being. Options B, C, and D are not the immediate priorities in this situation. While an eye examination, oxygen use, and sensitivity tests are relevant aspects of care, addressing dehydration through increased fluid intake takes precedence in this scenario.