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A client with a history of hypertension is admitted with a blood pressure of 200/110 mmHg. Which intervention should the nurse implement first?
- A. Administer an antihypertensive medication as prescribed.
- B. Monitor the client's urine output.
- C. Administer oxygen therapy as prescribed.
- D. Obtain an arterial blood gas (ABG) sample.
Correct Answer: D
Rationale: The correct answer is to obtain an arterial blood gas (ABG) sample. In a client with severe hypertension, it is essential to assess for metabolic or respiratory acidosis which can be done through an ABG sample. Administering antihypertensive medication without assessing the acid-base status of the client can lead to potential complications. Monitoring urine output and administering oxygen therapy are important interventions but are not the priority in this situation where the focus should be on assessing acidosis.
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A 35-year-old female client has just been admitted to the post-anesthesia recovery unit following a partial thyroidectomy. Which statement reflects the nurse's accurate understanding of the expected outcome for the client following this surgery?
- A. Supplemental hormonal therapy will probably be unnecessary.
- B. The thyroid will regenerate to a normal size within a few years.
- C. The client will be restricted from eating seafood.
- D. The remainder of the thyroid will be removed at a later date.
Correct Answer: C
Rationale: After a partial thyroidectomy, the client may be advised to avoid eating seafood due to its high iodine content, which can affect the thyroid function. Choice A is incorrect because after a partial thyroidectomy, supplemental hormonal therapy may be necessary. Choice B is incorrect as the thyroid does not regenerate after a partial thyroidectomy. Choice D is incorrect; the remaining portion of the thyroid is not typically removed at a later date unless there are specific medical reasons to do so.
The nurse is preparing to administer an intramuscular injection to a client with muscle wasting in the gluteal region. What is the most appropriate site for the injection?
- A. Dorsogluteal site
- B. Ventrogluteal site
- C. Deltoid site
- D. Vastus lateralis site
Correct Answer: D
Rationale: The vastus lateralis site is the most appropriate for an IM injection in a client with muscle wasting in the gluteal region. Administering the injection in the vastus lateralis ensures effective medication delivery due to muscle wasting in the gluteal region, preventing potential complications associated with the dorsogluteal or ventrogluteal sites, which may not be suitable in this specific client case. The deltoid site is mainly used for smaller volumes of medication and may not be ideal for this scenario.
A client with chronic kidney disease (CKD) is receiving epoetin alfa (Epogen). Which laboratory value should the nurse monitor closely?
- A. Hemoglobin
- B. White blood cell count
- C. Serum potassium
- D. Serum creatinine
Correct Answer: C
Rationale: The correct answer is C: Serum potassium. When a client with chronic kidney disease (CKD) is receiving epoetin alfa (Epogen), monitoring serum potassium levels closely is crucial. Epoetin alfa stimulates red blood cell production, which can lead to an increase in potassium levels. Hyperkalemia is a potential risk in these clients. Monitoring hemoglobin levels (choice A) is important in assessing the effectiveness of epoetin alfa therapy, but it is not the laboratory value that poses an immediate risk related to the medication. White blood cell count (choice B) and serum creatinine (choice D) are not directly affected by epoetin alfa therapy and are not the priority laboratory values to monitor in this case.
A client with newly diagnosed hypertension is being taught about lifestyle modifications by a nurse. Which client statement indicates a need for further teaching?
- A. 'I will reduce my salt intake to help manage my blood pressure.'
- B. 'I will start exercising regularly to help control my blood pressure.'
- C. 'I will avoid drinking alcohol to help manage my blood pressure.'
- D. 'I will limit my caffeine intake to help control my blood pressure.'
Correct Answer: D
Rationale: The correct answer is D. Limiting caffeine intake is a positive lifestyle modification for managing hypertension. The statement indicates that the client understands the importance of reducing caffeine intake. Choices A, B, and C all reflect appropriate lifestyle modifications for managing hypertension, indicating good understanding by the client.
Which assessment finding indicates to the nurse a client's readiness for pulmonary function tests?
- A. Expresses an understanding of the procedure.
- B. NPO for 6 hrs.
- C. No known drug allergies.
- D. Intravenous access intact.
Correct Answer: A
Rationale: The correct answer is A: 'Expresses an understanding of the procedure.' This choice indicates that the client is mentally prepared for the pulmonary function tests, as understanding the procedure shows readiness and cooperation. Choices B, C, and D are incorrect. Choice B, 'NPO for 6 hrs,' pertains to fasting status and is not directly related to readiness for the test. Choice C, 'No known drug allergies,' is important information but does not specifically indicate readiness for pulmonary function tests. Choice D, 'Intravenous access intact,' is related to vascular access and not a direct indicator of readiness for the pulmonary function tests.