Nokea
A client with a history of heart failure is admitted with fatigue. The nurse should monitor the client for which of the following laboratory abnormalities?
- A. Elevated B-type natriuretic peptide (BNP).
- B. Decreased creatinine.
- C. Increased albumin.
- D. Decreased sodium.
Correct Answer: A, D
Rationale: Elevated BNP indicates heart failure severity, and hyponatremia is common due to fluid overload.
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The nurse assesses the environmental safety of a client receiving home oxygen therapy. Which observation by the nurse indicates that the client needs further teaching to ensure safety?
- A. Oxygen used 30 feet from a gas stove
- B. Oxygen tank stored in the tank holder
- C. No smoking' sign posted at the front door
- D. Oxygen concentrator propped against a wall
Correct Answer: D
Rationale: The oxygen concentrator should be free and clear of walls or other enclosed spaces to allow adequate air circulation around the unit; otherwise, the unit can overheat and increase the risk of fire. Clients should avoid using oxygen within 10 feet of open flames because oxygen fuels a fire. Oxygen tanks are secured in a holder to stabilize and protect the tank, and a 'no smoking' sign should be in view to alert visitors about the risk.
The nurse is planning to assist the physician with a thoracentesis for a client who has a pleural effusion. Which of the following positions would be appropriate for the client to assume?
- A. Lying supine with the arms extended.
- B. Lying prone with the head supported by the arms.
- C. Sitting upright and leaning on an overbed table.
- D. Side-lying with the knees drawn up to the abdomen.
Correct Answer: C
Rationale: Sitting upright and leaning on an overbed table facilitates access to the pleural space and ensures client comfort during thoracentesis.
A client is admitted with a suspected myocardial infarction. The nurse should prioritize which of the following interventions?
- A. Administer aspirin as ordered.
- B. Obtain a 12-lead ECG.
- C. Insert an I.V. line.
- D. Administer morphine for pain.
Correct Answer: B
Rationale: Obtaining a 12-lead ECG is the priority to confirm myocardial infarction and guide treatment.
A client has just been admitted with acute delirium of unknown etiology. The client's daughter states that she is worried about her mom because she has never acted this way before. The nurse's best response is:
- A. I understand your concern. Let's discuss what specific changes you've noticed.'
- B. Delirium is common in older adults and usually resolves quickly.'
- C. We'll run some tests to find out what's causing this behavior.'
- D. Don't worry, we'll take good care of her.'
Correct Answer: A
Rationale: Discussing specific changes encourages the daughter to provide details, aiding in identifying the delirium's cause and tailoring care.
Your client has a doctor's order for the antihistamine medication diphenhydramine for sleep. What should you do?
- A. Question the order because Benadryl is an antihistamine and not a sleeping medication.
- B. Refuse to give the Benadryl because this medication is a stimulant.
- C. Question the order because Benadryl is contraindicated when the client has a sleep inducement disorder.
- D. Give the Benadryl because sleep inducement is an accepted off label use of this medication.
Correct Answer: D
Rationale: Diphenhydramine (Benadryl) is commonly used off-label for sleep due to its sedative properties, making it appropriate if ordered for this purpose.