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A client with a renal calculus reports severe right flank pain, nausea, and vomiting. Which nursing problem has the highest priority?
- A. Impaired renal function related to pain.
- B. Acute pain related to renal calculus.
- C. Risk for aspiration related to vomiting.
- D. Nutritional deficit related to nausea.
Correct Answer: C
Rationale: Risk for aspiration is the highest priority due to the immediate threat of airway obstruction from vomiting.
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After falling down the basement steps, a client is brought to the emergency department. X-ray results confirm that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?
- A. Increased temperature to lower extremity.
- B. Circumferential edema of right foot.
- C. Right foot pale with sluggish capillary refill.
- D. Reports throbbing right leg pain.
Correct Answer: C
Rationale: Pale foot with sluggish capillary refill indicates compromised circulation, risking tissue ischemia requiring urgent intervention.
A client reports to the clinic nurse of recently experiencing symptoms of frequent urination, hunger, and great thirst. What finding(s) would the nurse consider as most significant to report to the healthcare provider? Select all that apply.
- A. Total cholesterol 180 mg/dL (4.7 mmol/L).
- B. Hematocrit 45% (0.45 volume fraction).
- C. Random plasma glucose level 200 mg/dL (11.1 mmol/L).
- D. Hemoglobin A1C 7%.
- E. Serum potassium of 4.2 mEq/L (4.2 mmol/L).
Correct Answer: C,D
Rationale: Elevated glucose and HbA1C indicate diabetes, correlating with the client's symptoms and requiring urgent management.
A client who works as a data entry clerk is concerned as to how a recent diagnosis of Raynaud's syndrome is going to affect the client's job performance. Which instruction should the nurse provide this client?
- A. Use a space heater to keep the workspace warm.
- B. Take a multivitamin that contains vitamin D daily.
- C. Keep both hands elevated during work breaks.
- D. Obtain a keyboard designed to limit wrist flexion.
Correct Answer: A
Rationale: A warm workspace prevents vasospasm, reducing Raynaud's attacks during work.
History & Physical
Initial Assessment Findings
Chief Complaint: Acute asthma attack after jogging; worsened by outdoor activity and exercise.
Current Treatment: Used rescue inhaler three times, expired inhaler, worried about effectiveness.
Patient Data
Exhibits
The nurse has identified the priority problem for the client and now must determine proper care interventions.
Based on the client's history and the assessment data, what action(s) should the nurse anticipate? Select all that apply.
- A. Administer medications as ordered.
- B. Provide client teaching.
- C. Place the client in Trendelenburg position
- D. Ask the client for a list of current medications.
- E. Notify the healthcare provider of the client's need for intubation
- F. Apply oxygen via nasal cannula
Correct Answer: A,B,D,F
Rationale: Administering medications and oxygen (F) address the acute asthma attack. Obtaining a medication list ensures safe treatment, and teaching prevents future exacerbations. Trendelenburg position is inappropriate, and intubation is premature without further assessment.
The nurse is caring for a client after a coronary artery bypass graft surgery. The client is exhibiting pitting edema of the lower extremities and jugular venous distention with increased central venous pressure. Which condition should the nurse suspect the client is experiencing based on these findings?
- A. Right-sided heart failure.
- B. Left ventricular dysfunction.
- C. Cardiac tamponade.
- D. Internal bleeding.
Correct Answer: A
Rationale: Right-sided heart failure causes systemic venous congestion, leading to edema, jugular distention, and elevated central venous pressure.