Nokea
A client with a history of chronic heart failure is admitted with shortness of breath. Which assessment finding is most concerning?
- A. Crackles in the lungs
- B. Shortness of breath
- C. Elevated liver enzymes
- D. Heart rate of 100 beats per minute
Correct Answer: C
Rationale: Elevated liver enzymes are concerning in a client with chronic heart failure as they may indicate liver congestion or worsening heart failure, requiring immediate intervention. While crackles in the lungs and shortness of breath are common in heart failure, elevated liver enzymes specifically point towards possible liver involvement due to heart failure. A heart rate of 100 beats per minute can be expected in a client with heart failure due to compensatory mechanisms, but elevated liver enzymes signal a more severe condition.
You may also like to solve these questions
The nurse is preparing a 50 ml dose of 50% dextrose IV for a client with insulin shock. What is the most immediate intervention by the nurse?
- A. Dilute the dextrose in one liter of 0.9% Normal Saline solution.
- B. Mix the dextrose in a 50 ml piggyback for a total volume of 100 ml.
- C. Push the undiluted dextrose slowly through the current IV infusion.
- D. Ask the pharmacist to add the dextrose to a TPN solution.
Correct Answer: C
Rationale: The correct immediate intervention by the nurse in this situation is to push the undiluted 50% dextrose slowly through the current IV infusion. This is because in cases of insulin shock, where the client has dangerously low blood sugar levels, administering 50% dextrose directly into the bloodstream helps rapidly increase blood glucose levels. Choice A is incorrect because diluting the dextrose in one liter of normal saline would delay the administration of glucose, which is needed urgently. Choice B is incorrect as mixing the dextrose in a piggyback solution would also delay the administration of the concentrated dextrose. Choice D is incorrect because adding dextrose to a TPN solution is not the immediate intervention needed to address the low blood sugar levels in a client experiencing insulin shock.
A client with acute pancreatitis is admitted with severe abdominal pain. Which assessment finding requires immediate intervention?
- A. Severe abdominal distention
- B. Decreased urine output
- C. Decreased bowel sounds
- D. Increased heart rate
Correct Answer: A
Rationale: Severe abdominal distention is a sign of worsening pancreatitis and can indicate complications like bowel obstruction or fluid accumulation. Immediate intervention is necessary to prevent further deterioration. Decreased urine output (Choice B) could indicate renal impairment, decreased bowel sounds (Choice C) are expected in pancreatitis due to paralytic ileus, and an increased heart rate (Choice D) is a common response to pain or stress in acute pancreatitis but may not require immediate intervention unless it is extremely high or persistent.
The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250 ml of D5W at 300 mcg/hour. The nurse should program the infusion pump to deliver how many ml/hour?
- A. 50 ml/hour
- B. 25 ml/hour
- C. 75 ml/hour
- D. 100 ml/hour
Correct Answer: C
Rationale: To calculate the infusion rate, convert 1 mg to 1,000 mcg (1 mg = 1,000 mcg) and then use the formula D/H x Q, where D is the desired dose, H is the dose on hand, and Q is the quantity of solution. In this case, it would be 300 mcg/hour / 1,000 mcg x 250 ml = 75 ml/hour. Therefore, the nurse should program the infusion pump to deliver 75 ml/hour. Choice A (50 ml/hour), Choice B (25 ml/hour), and Choice D (100 ml/hour) are incorrect as they do not correspond to the calculated rate of 75 ml/hour.
A client is admitted with a diagnosis of sepsis. Which assessment finding is most concerning to the nurse?
- A. Temperature of 101.5°F
- B. Heart rate of 110 beats per minute
- C. Respiratory rate of 24 breaths per minute
- D. Blood pressure of 90/60 mmHg
Correct Answer: D
Rationale: A blood pressure of 90/60 mmHg in a client with sepsis is concerning for septic shock, a life-threatening condition that requires immediate intervention. Hypotension is a severe manifestation of sepsis that can lead to poor tissue perfusion and organ failure. While the other assessment findings such as an elevated temperature, increased heart rate, and respiratory rate are also common in sepsis, hypotension is particularly alarming as it indicates a critical state of shock and necessitates urgent medical attention.
The nurse is caring for a client with a tracheostomy who has thick, tenacious secretions. Which assessment finding is most concerning?
- A. Crepitus around the tracheostomy site
- B. Dry and cracked tracheostomy site
- C. Yellowing of the skin around the tracheostomy site
- D. Mucous plugging of the tracheostomy tube
Correct Answer: D
Rationale: Mucous plugging of the tracheostomy tube is the most concerning finding in a client with a tracheostomy and thick secretions. This can lead to airway obstruction, which requires immediate intervention to maintain a patent airway. Crepitus around the tracheostomy site may indicate subcutaneous emphysema but does not pose an immediate threat to the airway. A dry and cracked tracheostomy site may require interventions to promote healing but is not as urgent as mucous plugging. Yellowing of the skin around the tracheostomy site could indicate infection or impaired circulation, which should be addressed but does not pose the same immediate risk as airway obstruction.