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A client with acute pancreatitis is admitted with severe abdominal pain. Which assessment finding should be reported to the healthcare provider immediately?
- A. Decreased bowel sounds
- B. Increased heart rate
- C. Decreased urine output
- D. Elevated blood glucose level
Correct Answer: C
Rationale: Decreased urine output is concerning in a client with acute pancreatitis as it may indicate hypovolemia or renal impairment. In acute pancreatitis, decreased urine output can signify inadequate perfusion to the kidneys, leading to renal failure. While the other options are important to monitor in a client with acute pancreatitis, decreased urine output requires immediate attention to prevent further complications.
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A client with chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. 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 indicates increased work of breathing and can signal respiratory failure in a client with COPD. This finding requires immediate intervention to prevent further respiratory compromise. Oxygen saturation of 90% indicates some oxygenation impairment but may not necessitate immediate intervention. A respiratory rate of 24 breaths per minute is slightly elevated but does not indicate immediate respiratory distress. Inspiratory crackles may be present in pneumonia but do not require immediate intervention compared to the increased work of breathing indicated by the use of accessory muscles.
A client with rheumatoid arthritis is scheduled to receive a dose of methotrexate. Which laboratory result is most important for the nurse to review before administering the medication?
- A. White blood cell count
- B. Liver function tests
- C. Kidney function tests
- D. Complete blood count
Correct Answer: B
Rationale: The correct answer is B: Liver function tests. Before administering methotrexate, it is crucial to review liver function tests due to the medication's potential hepatotoxic effects. Methotrexate can cause liver damage, so monitoring liver function is essential to prevent any serious complications. While white blood cell count, kidney function tests, and complete blood count are important parameters to monitor in certain situations, they are not the most critical before administering methotrexate.
A female client receives a prescription for alendronate sodium (Fosamax) to treat her newly diagnosed osteoporosis. What instruction should the nurse include in the client's teaching plan?
- A. Take on an empty stomach with a full glass of water.
- B. Take with food to avoid stomach upset.
- C. Take before bedtime with a light snack.
- D. Take with milk to enhance absorption.
Correct Answer: A
Rationale: The correct answer is to take alendronate on an empty stomach with a full glass of water. This instruction is essential to ensure proper absorption and prevent esophageal irritation. Taking alendronate with food, before bedtime with a light snack, or with milk can interfere with its absorption and effectiveness, leading to potential side effects or reduced therapeutic benefits.
The healthcare provider is assessing a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which clinical finding is most concerning?
- A. Increased fatigue
- B. Elevated blood pressure
- C. Elevated hemoglobin
- D. Low urine output
Correct Answer: B
Rationale: In a client with chronic kidney disease (CKD) receiving erythropoietin therapy, elevated blood pressure is the most concerning finding. Elevated blood pressure can indicate worsening hypertension, which requires immediate intervention to prevent further damage to the kidneys and other organs. Increased fatigue (choice A) is a common symptom in CKD but may not be as acutely concerning as elevated blood pressure. Elevated hemoglobin (choice C) can be an expected outcome of erythropoietin therapy and is not necessarily concerning. Low urine output (choice D) is important to monitor in CKD but may not be as immediately concerning as elevated blood pressure in this context.
A client with cirrhosis is admitted with hepatic encephalopathy. Which clinical finding is most concerning?
- A. Confusion and altered mental status
- B. Increased abdominal girth
- C. Yellowing of the skin
- D. Peripheral edema
Correct Answer: A
Rationale: Confusion and altered mental status are the most concerning clinical findings in a client with hepatic encephalopathy. These symptoms indicate worsening liver function and potential neurological complications, requiring immediate medical attention. Increased abdominal girth may suggest ascites, yellowing of the skin can indicate jaundice, and peripheral edema may be related to fluid retention, but in the context of hepatic encephalopathy, confusion and altered mental status take precedence due to the risk of rapid deterioration and the need for prompt management.