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A client with a history of myocardial infarction is admitted with chest pain. Which diagnostic test should the nurse anticipate preparing the client for first?
- A. Electrocardiogram (ECG)
- B. Chest X-ray
- C. Arterial blood gases (ABGs)
- D. Echocardiogram
Correct Answer: A
Rationale: The correct answer is A: Electrocardiogram (ECG). An electrocardiogram should be performed first to assess for cardiac ischemia in a client with a history of myocardial infarction and chest pain. This test provides immediate information about the heart's electrical activity. Choice B, Chest X-ray, is used to visualize the structures of the chest, including the heart and lungs, but it does not directly assess for cardiac ischemia. Choice C, Arterial blood gases (ABGs), measures the oxygen and carbon dioxide levels in the blood and assesses acid-base balance, which is not the primary concern in this scenario. Choice D, Echocardiogram, is an ultrasound of the heart that provides information about the heart's structure and function, but it is not the initial diagnostic test for assessing cardiac ischemia in this situation.
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A client with rapid respirations and audible rhonchi is admitted to the intensive care unit because of a pulmonary embolism (PE). Low-flow oxygen by nasal cannula and weight-based heparin protocol are initiated. Which intervention is most important for the nurse to include in this client's plan of care?
- A. Evaluate blood clotting factors daily.
- B. Encourage incentive spirometry use.
- C. Administer pain medication as needed.
- D. Monitor for signs of bleeding.
Correct Answer: A
Rationale: Evaluating blood clotting factors daily is crucial when a client is on heparin therapy to monitor for potential complications such as bleeding or clotting issues. This monitoring helps ensure that the heparin dose is within the therapeutic range and reduces the risk of bleeding or clotting complications. Encouraging incentive spirometry use is beneficial for preventing atelectasis and improving lung function, but in this scenario, monitoring blood clotting factors takes precedence. Administering pain medication as needed is important for the client's comfort but is not the priority in managing a pulmonary embolism. Monitoring for signs of bleeding is important due to heparin therapy, but evaluating blood clotting factors provides more specific information on the client's response to treatment.
A client with diabetes mellitus is admitted with a blood glucose level of 600 mg/dl and is unresponsive. Which laboratory value is most concerning?
- A. Serum potassium of 3.0 mEq/L
- B. Serum glucose of 200 mg/dl
- C. Serum pH of 7.30
- D. Serum sodium of 135 mEq/L
Correct Answer: C
Rationale: In a client with Hyperosmolar Hyperglycemic State (HHS), a serum pH of 7.30 is the most concerning value as it indicates acidosis, a life-threatening condition that requires immediate intervention. Choices A, B, and D are not the most concerning in this scenario. A low serum potassium level (Choice A) may be expected due to cellular shift in hyperglycemia, a serum glucose level of 200 mg/dl (Choice B) is not as concerning compared to the extremely high initial glucose level, and a serum sodium level of 135 mEq/L (Choice D) is within the normal range and not the immediate priority.
A client is admitted with a diagnosis of diabetic ketoacidosis (DKA). Which clinical finding is most concerning to the nurse?
- A. Kussmaul respirations
- B. Blood glucose level of 300 mg/dl
- C. Serum potassium of 3.2 mEq/L
- D. Positive urine ketones
Correct Answer: C
Rationale: The correct answer is C: Serum potassium of 3.2 mEq/L. A low serum potassium level in a client with DKA is concerning due to the risk of cardiac arrhythmias. Kussmaul respirations (choice A) are a compensatory mechanism for metabolic acidosis in DKA. A blood glucose level of 300 mg/dl (choice B) is elevated but expected in DKA. Positive urine ketones (choice D) are a classic finding in DKA and not as concerning as low serum potassium.
A client with a postoperative wound that eviscerated yesterday has an elevated temperature. Which intervention is most important for the nurse to implement?
- A. Initiate contact isolation.
- B. Obtain a wound swab for culture and sensitivity.
- C. Assess temperature every 4 hours.
- D. Use alcohol-based solutions for hand hygiene.
Correct Answer: B
Rationale: In this scenario, the most critical intervention is to obtain a wound swab for culture and sensitivity. This will help identify the causative organism present in the wound, enabling healthcare providers to prescribe the appropriate treatment. Initiating contact isolation (Choice A) may be necessary in certain situations but is not the priority in this case where infection is suspected. Assessing the temperature (Choice C) is important for monitoring the client's condition but does not address the underlying cause. Using alcohol-based solutions for hand hygiene (Choice D) is a standard practice for infection control but does not directly address the client's specific condition of a postoperative wound with evisceration and elevated temperature.
A male client with diabetes mellitus type 2, who is taking pioglitazone PO daily, reports to the nurse the recent onset of nausea, accompanied by dark-colored urine, and a yellowish cast to his skin. What instructions should the nurse provide?
- A. Seek immediate medical assistance to evaluate the cause of these symptoms.
- B. Discontinue the medication and follow up with a healthcare provider.
- C. Increase fluid intake and monitor urine color.
- D. Continue taking the medication and report any changes.
Correct Answer: A
Rationale: The correct answer is A: 'Seek immediate medical assistance to evaluate the cause of these symptoms.' The symptoms described by the client, including nausea, dark-colored urine, and yellowish skin, are indicative of possible liver toxicity, a serious side effect of pioglitazone. Therefore, immediate medical evaluation is necessary to assess the severity of the condition and prevent further complications. Choices B, C, and D are incorrect: B advises discontinuing the medication without seeking immediate medical assistance, which could delay necessary treatment; C focuses solely on increasing fluid intake and monitoring urine color, overlooking the urgency of the situation; and D suggests continuing the medication when prompt evaluation is crucial in this scenario.