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A client with a history of heart failure is admitted with pulmonary edema. Which finding requires immediate intervention?
- A. Peripheral edema.
- B. Oxygen saturation of 88%.
- C. Jugular vein distention.
- D. Productive cough with pink, frothy sputum.
Correct Answer: D
Rationale: A productive cough with pink, frothy sputum is a classic sign of pulmonary edema, indicating fluid in the lungs. This finding requires immediate intervention to prevent respiratory compromise and worsening of the condition. Peripheral edema (Choice A) is a manifestation of heart failure but is not as urgent as addressing pulmonary edema. Oxygen saturation of 88% (Choice B) is low and requires attention, but the pink, frothy sputum signifies acute respiratory distress. Jugular vein distention (Choice C) can be seen in heart failure, but the immediate concern in this scenario is addressing the pulmonary edema to ensure adequate gas exchange and oxygenation.
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The healthcare provider provides teaching to a group of evacuees in a mass casualty center after a natural flooding disaster. Which information should the healthcare provider include in the teaching plan? (select one that does not apply.)
- A. wash all fruits and vegetables thoroughly in running tap water
- B. identify all sexual contacts since the evacuation process
- C. take all doses of prophylactic prescriptions for diarrhea
- D. clean hands using soap, clean water, or waterless antibacterial solutions
Correct Answer: B
Rationale: In the aftermath of a flooding disaster, educating evacuees on proper hygiene practices like washing fruits and vegetables, taking prophylactic prescriptions, and practicing hand hygiene is crucial to prevent the spread of diseases. Option B, identifying sexual contacts, is not relevant to preventing post-disaster health risks and should not be included in the teaching plan.
The healthcare provider is caring for a client with hyperparathyroidism. Which laboratory result requires immediate intervention?
- A. Serum calcium of 11 mg/dL.
- B. Serum phosphorus of 3 mg/dL.
- C. Serum magnesium of 1.8 mg/dL.
- D. Serum albumin of 4 g/dL.
Correct Answer: A
Rationale: A serum calcium level of 11 mg/dL indicates hypercalcemia, which can be a complication of hyperparathyroidism and requires immediate intervention. Hypercalcemia can lead to serious complications such as cardiac dysrhythmias, renal failure, and neurologic symptoms. Monitoring and managing serum calcium levels are crucial in clients with hyperparathyroidism. Serum phosphorus, magnesium, and albumin levels are important to assess in clients with hyperparathyroidism, but they do not require immediate intervention as hypercalcemia poses a more urgent risk.
The healthcare provider is assessing a client who has returned from hemodialysis. Which finding requires immediate intervention?
- A. Weight gain of 1 pound.
- B. Dizziness.
- C. Fatigue.
- D. Muscle cramps.
Correct Answer: D
Rationale: After hemodialysis, muscle cramps can indicate an electrolyte imbalance, such as low potassium or magnesium levels, which requires immediate intervention to prevent potential complications like cardiac arrhythmias. Weight gain of 1 pound, dizziness, and fatigue are common post-hemodialysis symptoms that may not necessarily require immediate intervention unless they are severe or persisting.
On a day when the temperature is expected to drop below freezing during the night, the nurse is asked to determine which homeless adults are most in need of the limited spaces available in a shelter. It is most important for which person to be admitted at night?
- A. an adult who was hit by a car 3 weeks ago
- B. a young person with diabetes mellitus
- C. a middle-aged person who has hypertension
- D. an older person who is malnourished
Correct Answer: D
Rationale: Malnourished individuals are at higher risk of severe complications from cold exposure due to their weakened immune system and decreased ability to regulate body temperature. This places them at a greater risk of hypothermia and other cold-related conditions, making them the most vulnerable group in need of shelter. Choice A is not the most critical as the injury is from 3 weeks ago and should have received appropriate medical care by now. Choice B, a young person with diabetes mellitus, while vulnerable, can manage their condition with proper medication and care. Choice C, a middle-aged person with hypertension, may need monitoring but is less susceptible to immediate harm from cold exposure compared to a malnourished individual.
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. Which finding indicates that the therapy is effective?
- A. The client is able to expectorate secretions easily.
- B. The client's oxygen saturation is 92%.
- C. The client's respiratory rate is 20 breaths per minute.
- D. The client's arterial blood gases show a pH of 7.35.
Correct Answer: C
Rationale: In a client with COPD receiving oxygen therapy, an effective response is indicated by a respiratory rate of 20 breaths per minute. This suggests that the client is effectively oxygenating while maintaining an appropriate respiratory rate. Choices A, B, and D are incorrect because expectorating secretions easily, having an oxygen saturation of 92%, and arterial blood gases showing a pH of 7.35 are not specific indicators of the effectiveness of oxygen therapy in COPD. Oxygen saturation of 92% may still be suboptimal in COPD, and arterial blood gases showing a pH of 7.35 may not necessarily reflect the overall effectiveness of oxygen therapy.