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A client with a history of heart failure is admitted with worsening symptoms. The nurse should monitor the client for which of the following laboratory abnormalities? Select all that apply.
- A. Hyponatremia.
- B. Hyperkalemia.
- C. Elevated B-type natriuretic peptide (BNP).
- D. Hypomagnesemia.
- E. Elevated creatinine.
Correct Answer: A, C, E
Rationale: Heart failure can cause hyponatremia (fluid overload), elevated BNP (cardiac stress), and elevated creatinine (renal impairment).
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A client develops an irregular heart rate. Which statement made by the client who has developed an irregular heart rate indicates to the nurse that the client is ready for learning?
- A. I feel weak with an irregular pulse.
- B. What is it like to have a pacemaker?
- C. All my medications will be changed now.
- D. How can this heart rate problem affect me?
Correct Answer: D
Rationale: Learning depends on two things: physical and emotional readiness to learn. A good time to teach is when the client indicates an interest in learning, is motivated, and is physically capable of concentrating on learning. Option 4 addresses the client's readiness because the client is directly asking about the disorder. Option 1 indicates that the client is potentially physically incapable of learning at this time. The client indicates wanting to learn about pacemakers in option 2; however, the client has formed a hasty conclusion because the need for a pacemaker has not been determined. In option 3, by assuming that the medications will change, the client is emotionally unprepared for learning because the statement is based on incomplete data.
The nurse has administered a dose of diazepam to the client. Which most important action should the nurse take before leaving the client's room?
- A. Draw the shades closed.
- B. Provide the client access to a bedpan.
- C. Turn the volume on the television down.
- D. Instruct the client not to get out of bed without assistance.
Correct Answer: D
Rationale: Diazepam is a benzodiazepine and has sedative/hypnotic effects with anticonvulsant and skeletal muscle relaxant properties. The nurse should institute safety measures before leaving the client's room to ensure that the client does not injure self. The most frequent side effects of this medication are dizziness, drowsiness, and lethargy. For this reason, the nurse raises a side rail on the bed and instructs the client not to get out of bed without assistance. Note that agency policy regarding the use of side rails is always followed. Although the remaining options may be helpful measures that provide a comfortable, restful environment, instructing the client to ask for assistance when getting out of bed provides for the client's safety needs.
The nurse is teaching a client with a new diagnosis of gout about medication management. Which of the following medications should the client expect to take for long-term management?
- A. Allopurinol.
- B. Colchicine.
- C. Indomethacin.
- D. Prednisone.
Correct Answer: A
Rationale: Allopurinol reduces uric acid production for long-term gout management.
A client with a diagnosis of gout is prescribed febuxostat (Uloric). The nurse should instruct the client to:
- A. Take the medication with food to reduce stomach upset.
- B. Avoid drinking alcohol.
- C. Limit fluid intake.
- D. Take the medication at bedtime only.
Correct Answer: A,B
Rationale: Taking febuxostat with food reduces gastrointestinal upset, and avoiding alcohol prevents uric acid buildup.
Assessment of a nulligravid client in active labor reveals the following: complaints of moderate discomfort; cervix dilated $3 \mathrm{~cm}, 0$ station and completely effaced; fetal heart rate of $136 \mathrm{bpm}$. Which of the following should the nurse plan to do next?
- A. Assist the client with comfort measures and breathing techniques.
- B. Turn the client from the left side-lying position to the right side-lying position.
- C. Prepare the client for epidural anesthesia to relieve pain.
- D. Instruct the client that internal fetal monitoring is necessary.
Correct Answer: A
Rationale: Moderate discomfort in early labor is managed with non-pharmacologic comfort measures and breathing techniques to promote coping.