Nokea
A client with a history of chronic heart failure is admitted with shortness of breath and crackles in the lungs. Which intervention should the nurse implement first?
- A. Administer oxygen therapy as prescribed.
- B. Administer a loop diuretic as prescribed.
- C. Administer intravenous morphine as prescribed.
- D. Obtain an arterial blood gas (ABG) sample.
Correct Answer: A
Rationale: Administering oxygen therapy is the priority intervention for a client with chronic heart failure presenting with shortness of breath and crackles in the lungs. Oxygen therapy helps improve oxygenation, which is crucial in managing respiratory distress. Loop diuretics (Choice B) may be indicated to manage fluid overload in heart failure but are not the immediate priority in this case. Administering morphine (Choice C) is not the first-line intervention for shortness of breath in heart failure and should be considered after addressing oxygenation and underlying causes. Obtaining an arterial blood gas sample (Choice D) can provide valuable information but is not the initial action needed to address the client's acute respiratory distress.
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A male client with an antisocial personality disorder is admitted to an inpatient mental health unit for multiple substance dependencies. When providing a history, the client justifies to the nurse his use of illicit drugs. Based on this pattern of behavior, this client's history is most likely to include which finding?
- A. Multiple convictions for misdemeanors and class B felonies.
- B. A history of stable employment
- C. Strong relationships with family members
- D. A pattern of seeking help when needed
Correct Answer: A
Rationale: The correct answer is A: Multiple convictions for misdemeanors and class B felonies. Clients with antisocial personality disorder often engage in behaviors that disregard societal rules and norms, leading to legal issues and criminal activities. This behavior is characteristic of individuals with antisocial personality disorder. Choices B, C, and D are incorrect because individuals with this disorder are less likely to have stable employment, strong family relationships, or seek help when needed due to their pattern of defiance and disregard for authority and rules.
A woman who takes pyridostigmine for myasthenia gravis (MG) arrives at the emergency department complaining of extreme muscle weakness. Her adult daughter tells the nurse that since yesterday her mother has been unable to smile. Which assessment finding warrants immediate intervention by the nurse?
- A. Uncontrollable drooling.
- B. Inability to raise voice.
- C. Tingling of extremities.
- D. Eyelid drooping.
Correct Answer: A
Rationale: Uncontrollable drooling can be a sign of a myasthenic crisis, which requires immediate medical intervention to prevent respiratory failure. Drooling indicates difficulty in swallowing, which can lead to aspiration and respiratory compromise. Inability to raise voice (choice B) and tingling of extremities (choice C) are not typically associated with myasthenic crisis. Although eyelid drooping (choice D) is a common symptom of myasthenia gravis, it is not as urgent as uncontrollable drooling in indicating a potential crisis.
A client with end-stage renal disease (ESRD) is scheduled for hemodialysis. Which laboratory value should be reported to the healthcare provider before the procedure?
- A. Serum creatinine of 2.5 mg/dL
- B. Serum potassium of 6.5 mEq/L
- C. Serum calcium of 8 mg/dL
- D. Serum bicarbonate of 24 mEq/L
Correct Answer: B
Rationale: The correct answer is B. A serum potassium level of 6.5 mEq/L is dangerously high and should be reported before hemodialysis to prevent cardiac complications. High potassium levels can lead to life-threatening arrhythmias. Serum creatinine (Choice A) is elevated in renal dysfunction but not the most critical value to report before hemodialysis. Serum calcium (Choice C) and serum bicarbonate (Choice D) levels are within normal limits and are not immediate concerns before hemodialysis.
The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in keeping with the child's dietary restrictions. Which foods are contraindicated for this child?
- A. Wheat products
- B. Foods sweetened with aspartame
- C. High-fat foods
- D. High-calorie foods
Correct Answer: B
Rationale: The correct answer is B: Foods sweetened with aspartame. Aspartame should not be consumed by a child with PKU because it is converted to phenylalanine in the body, which can be harmful to individuals with PKU. Choice A (Wheat products) is not specifically contraindicated for PKU. Choice C (High-fat foods) and Choice D (High-calorie foods) are not typically restricted in PKU diets unless they contain high levels of phenylalanine.
The nurse is caring for a client with a chest tube in place following a pneumothorax. Which finding requires immediate intervention?
- A. Oxygen saturation of 95%
- B. Crepitus around the insertion site
- C. Subcutaneous emphysema
- D. Drainage of 50 ml per hour
Correct Answer: C
Rationale: Subcutaneous emphysema requires immediate intervention in a client with a chest tube following a pneumothorax as it can indicate a pneumothorax recurrence or air leak. Oxygen saturation of 95% is within the normal range and does not require immediate intervention. Crepitus around the insertion site can be expected post-procedure and may not necessitate immediate action. Drainage of 50 ml per hour is a normal finding and does not raise immediate concerns.