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A client with a history of chronic heart failure is admitted with shortness of breath. Which laboratory value should be closely monitored?
- A. Serum sodium level
- B. Serum potassium level
- C. Serum creatinine level
- D. Hemoglobin level
Correct Answer: B
Rationale: Corrected Rationale: In a client with chronic heart failure, serum potassium levels should be closely monitored to assess for hyperkalemia, which can worsen heart failure. Monitoring serum sodium levels is not the priority in this case. Serum creatinine level monitoring is more related to kidney function than heart failure. Hemoglobin levels are important but not the primary concern when assessing heart failure exacerbation.
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An elderly male client is admitted to the urology unit with acute renal failure due to a postrenal obstruction. Which question best assists the nurse in obtaining relevant historical data?
- A. Have you had any difficulty starting your urinary stream?
- B. Do you have a history of kidney stones?
- C. How much fluid do you drink daily?
- D. Have you had any previous urinary tract infections?
Correct Answer: A
Rationale: The correct answer is A: 'Have you had any difficulty starting your urinary stream?' This question is the most relevant as difficulty starting urination can indicate an obstruction, which aligns with the client's current condition of postrenal obstruction causing acute renal failure. Choice B is incorrect as a history of kidney stones may not be directly related to the current obstruction. Choice C, asking about daily fluid intake, is not specific to the current issue of postrenal obstruction. Choice D inquires about previous urinary tract infections, which are not directly related to the current acute renal failure caused by postrenal obstruction.
A client with diabetes mellitus is admitted with a blood glucose level of 600 mg/dl and is unresponsive. Which laboratory value is most concerning?
- A. Serum potassium of 3.0 mEq/L
- B. Serum glucose of 200 mg/dl
- C. Serum pH of 7.30
- D. Serum sodium of 135 mEq/L
Correct Answer: C
Rationale: In a client with Hyperosmolar Hyperglycemic State (HHS), a serum pH of 7.30 is the most concerning value as it indicates acidosis, a life-threatening condition that requires immediate intervention. Choices A, B, and D are not the most concerning in this scenario. A low serum potassium level (Choice A) may be expected due to cellular shift in hyperglycemia, a serum glucose level of 200 mg/dl (Choice B) is not as concerning compared to the extremely high initial glucose level, and a serum sodium level of 135 mEq/L (Choice D) is within the normal range and not the immediate priority.
When planning care for a 10-year-old child with pneumonia receiving oxygen at 5l/min per nasal cannula, what principle of oxygen administration should the nurse consider?
- A. Avoid administration of oxygen at high levels for extended periods.
- B. Increase oxygen flow rate if the child is still tachypneic.
- C. Reduce oxygen levels gradually after symptoms improve.
- D. Humidify the oxygen to prevent drying of mucous membranes.
Correct Answer: A
Rationale: The correct principle of oxygen administration to consider is to avoid administering oxygen at high levels for extended periods. High levels of oxygen for prolonged periods can lead to oxygen toxicity, especially in pediatric patients. Increasing the oxygen flow rate based on tachypnea may not be necessary and can potentially lead to oxygen toxicity. Gradually reducing oxygen levels after symptoms improve may compromise the child's oxygenation. While humidifying oxygen is important to prevent drying of mucous membranes, the primary concern in this case is to avoid high oxygen levels for an extended duration to prevent oxygen toxicity.
The charge nurse of the critical care unit informed at the beginning of the shift that a less than optimal number of registered nurses would be working that shift. In planning assignments, which client should receive the most care hours by a registered nurse?
- A. A 34-year-old admitted today after an emergency appendectomy who has a peripheral intravenous catheter and a Foley catheter.
- B. A 48-year-old marathon runner with a central venous catheter experiencing nausea and vomiting due to electrolyte disturbance following a race.
- C. A 63-year-old chain smoker with chronic bronchitis receiving oxygen via nasal cannula and a saline-locked peripheral intravenous catheter.
- D. An 82-year-old client with Alzheimer's disease and a newly fractured femur with a Foley catheter and soft wrist restraints applied.
Correct Answer: D
Rationale: The 82-year-old client with Alzheimer's disease and a newly fractured femur should receive the most care hours by a registered nurse because they are at the highest risk for injury and complications. The client's age, diagnosis of Alzheimer's disease, and the presence of a newly fractured femur along with the Foley catheter and wrist restraints indicate a need for close monitoring and care. Choice A is less critical as the client is stable post-appendectomy. Choice B, though experiencing symptoms, is not at the same level of risk as the client in Choice D. Choice C, while requiring oxygen support, does not have the same level of acuity and complexity as the client in Choice D.
A client with a history of myocardial infarction is admitted with chest pain. Which diagnostic test should the nurse anticipate preparing the client for first?
- A. Electrocardiogram (ECG)
- B. Chest X-ray
- C. Arterial blood gases (ABGs)
- D. Echocardiogram
Correct Answer: A
Rationale: The correct answer is A: Electrocardiogram (ECG). An electrocardiogram should be performed first to assess for cardiac ischemia in a client with a history of myocardial infarction and chest pain. This test provides immediate information about the heart's electrical activity. Choice B, Chest X-ray, is used to visualize the structures of the chest, including the heart and lungs, but it does not directly assess for cardiac ischemia. Choice C, Arterial blood gases (ABGs), measures the oxygen and carbon dioxide levels in the blood and assesses acid-base balance, which is not the primary concern in this scenario. Choice D, Echocardiogram, is an ultrasound of the heart that provides information about the heart's structure and function, but it is not the initial diagnostic test for assessing cardiac ischemia in this situation.