Nokea
A client with acute pancreatitis is admitted with severe abdominal pain. Which assessment finding requires immediate intervention?
- A. Severe abdominal distention
- B. Decreased urine output
- C. Decreased bowel sounds
- D. Increased heart rate
Correct Answer: A
Rationale: Severe abdominal distention is a sign of worsening pancreatitis and can indicate complications like bowel obstruction or fluid accumulation. Immediate intervention is necessary to prevent further deterioration. Decreased urine output (Choice B) could indicate renal impairment, decreased bowel sounds (Choice C) are expected in pancreatitis due to paralytic ileus, and an increased heart rate (Choice D) is a common response to pain or stress in acute pancreatitis but may not require immediate intervention unless it is extremely high or persistent.
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An adolescent's mother calls the clinic because the teen is having recurrent vomiting and has been combative in the last 2 days. The mother states that the teen takes vitamins, calcium, and magnesium supplements along with aspirin. Which nursing intervention has the highest priority?
- A. Advise the mother to withhold all medications by mouth.
- B. Instruct the mother to take the teen to the emergency room.
- C. Recommend that the teen withhold food and fluids for 2 hours.
- D. Suggest that the adolescent breathe slowly and deeply.
Correct Answer: B
Rationale: In this scenario, the highest priority nursing intervention is to instruct the mother to take the teen to the emergency room. The symptoms of recurrent vomiting, combative behavior, and the medications (vitamins, calcium, magnesium supplements, and aspirin) taken by the teen suggest a possible overdose or serious adverse reaction. Therefore, immediate medical evaluation is crucial to assess and manage any potential toxicity or adverse effects. Advising to withhold all medications by mouth (Choice A) may delay necessary treatment. Recommending withholding food and fluids for 2 hours (Choice C) may not address the underlying cause of the symptoms. Suggesting slow and deep breathing (Choice D) is not appropriate in this urgent situation requiring immediate medical attention.
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which assessment finding requires immediate intervention?
- A. Oxygen saturation of 90%
- B. Respiratory rate of 24 breaths per minute
- C. Use of accessory muscles
- D. Inspiratory crackles
Correct Answer: C
Rationale: The correct answer is C. The use of accessory muscles is most concerning in a client with COPD receiving supplemental oxygen as it indicates increased work of breathing, requiring immediate intervention. Oxygen saturation of 90% is acceptable in a client with COPD. A respiratory rate of 24 breaths per minute is slightly elevated but not as critical as the use of accessory muscles. Inspiratory crackles may be present in clients with COPD due to underlying lung changes but do not require immediate intervention unless associated with other concerning symptoms.
A client with hypertension receives a prescription for enalapril, an angiotensin-converting enzyme inhibitor (ACEI). Which instruction should the nurse include in the medication teaching plan?
- A. Increase intake of potassium-rich foods
- B. Report increased bruising or bleeding
- C. Stop medication if a cough develops
- D. Limit intake of leafy green vegetables
Correct Answer: B
Rationale: The correct instruction for the nurse to include in the medication teaching plan for a client receiving enalapril, an ACE inhibitor, is to 'Report increased bruising or bleeding.' ACE inhibitors can cause thrombocytopenia, which can lead to an increased risk of bruising and bleeding. Monitoring and reporting these symptoms promptly are essential to prevent complications. Choices A, C, and D are incorrect because increasing potassium-rich foods, stopping medication if a cough develops, and limiting intake of leafy green vegetables are not directly related to the common side effects or actions of ACE inhibitors.
A client with a history of angina pectoris is prescribed sublingual nitroglycerin. Which client statement indicates that further teaching is needed?
- A. 'I should take the nitroglycerin with a full glass of water.'
- B. 'I should take the nitroglycerin as soon as I feel chest pain.'
- C. 'I can take up to three doses of nitroglycerin if needed.'
- D. 'I should call 911 if my chest pain does not improve after the first dose.'
Correct Answer: A
Rationale: The correct answer is A. Sublingual nitroglycerin should not be taken with water, as it needs to dissolve under the tongue to be effective. Option B is correct as the client should take nitroglycerin as soon as they feel chest pain. Option C is correct as up to three doses can be taken if needed. Option D is correct as the client should seek emergency help if chest pain does not improve after the first dose.
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which finding indicates the need for immediate intervention?
- A. Use of accessory muscles
- B. Oxygen saturation of 94%
- C. Carbon dioxide level of 45 mmHg
- D. Respiratory rate of 20 breaths per minute
Correct Answer: C
Rationale: A carbon dioxide level of 45 mmHg is concerning in a client with COPD receiving supplemental oxygen, as it may indicate carbon dioxide retention and requires immediate intervention. Options A, B, and D are not the priority findings in this scenario. While the use of accessory muscles, an oxygen saturation of 94%, and a respiratory rate of 20 breaths per minute are important to monitor in a client with COPD, they do not indicate an immediate need for intervention like an elevated carbon dioxide level does.