Nokea
A client with chronic heart failure is admitted with shortness of breath and a new onset of confusion. Which intervention should the nurse implement first?
- A. Obtain a neurological assessment.
- B. Administer oxygen therapy.
- C. Monitor the client's urine output.
- D. Obtain an electrocardiogram (ECG).
Correct Answer: A
Rationale: The correct answer is to obtain a neurological assessment. In a client with chronic heart failure presenting with confusion, the priority is to assess neurological status to rule out potential causes such as hypoxia or other complications. Administering oxygen therapy (Choice B) is important but assessing the neurological status takes precedence in this scenario. Monitoring urine output (Choice C) and obtaining an ECG (Choice D) may be necessary but are not the initial priority when a client presents with confusion alongside shortness of breath.
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A client with atrial fibrillation is receiving digoxin (Lanoxin) and warfarin (Coumadin). Which assessment finding should the nurse report to the healthcare provider immediately?
- A. Heart rate of 58 beats per minute
- B. Presence of a new murmur
- C. INR of 2.5
- D. Blood pressure of 110/70 mmHg
Correct Answer: B
Rationale: The correct answer is B. The presence of a new murmur in a client with atrial fibrillation may indicate a valvular problem or other complications, requiring immediate reporting. A heart rate of 58 beats per minute is within the normal range for some individuals with atrial fibrillation, so it is not an immediate concern. An INR of 2.5 is within the therapeutic range for a client on warfarin, indicating appropriate anticoagulation. A blood pressure of 110/70 mmHg is also within the normal range and does not pose an immediate threat to the client's health.
A client who is at 10-weeks gestation calls the clinic because she has been vomiting for the past 24 hours. The nurse determines that the client has no fever. Which instructions should the nurse give to this client?
- A. Come to the clinic to be seen by a healthcare provider
- B. Increase your fluid intake and rest at home
- C. Take over-the-counter antiemetics as needed
- D. Monitor your symptoms and call if they worsen
Correct Answer: A
Rationale: The correct answer is to advise the client to come to the clinic to be seen by a healthcare provider. Persistent vomiting during pregnancy can lead to dehydration, which requires medical evaluation. Choice B is incorrect because solely increasing fluid intake and resting at home may not be sufficient to address the potential dehydration and underlying causes of vomiting. Choice C is not recommended without medical evaluation, as over-the-counter antiemetics should be used under healthcare provider guidance during pregnancy. Choice D is not the best option here because with persistent vomiting and risk of dehydration, immediate medical assessment is crucial to ensure the well-being of both the client and the fetus.
After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To determine if an S3 heart sound is present, what action should the nurse take first?
- A. Slide the stethoscope across the sternum.
- B. Move the stethoscope to the mitral site.
- C. Listen with the bell at the same location.
- D. Observe the cardiac telemetry monitor.
Correct Answer: C
Rationale: The nurse uses the bell of the stethoscope to hear low-pitched sounds such as S3 and S4. To determine if an S3 heart sound is present, the nurse should listen at the same location using the bell first. This allows for the accurate identification of low-pitched sounds. Moving the stethoscope across the sternum (Choice A) or to the mitral site (Choice B) would not be the initial actions to assess for an S3 heart sound. Observing the cardiac telemetry monitor (Choice D) is not relevant for assessing S3 heart sounds, as it does not provide direct auscultation of heart sounds.
The nurse is assessing a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which laboratory value should be closely monitored?
- A. Serum potassium level
- B. Hemoglobin level
- C. White blood cell count
- D. Serum sodium level of 135 mEq/L
Correct Answer: A
Rationale: The correct answer is A: Serum potassium level. In clients receiving erythropoietin therapy for chronic kidney disease, monitoring serum potassium levels is crucial due to the risk of developing hyperkalemia. Erythropoietin therapy can stimulate red blood cell production, leading to an increase in potassium levels. Monitoring potassium levels helps prevent complications associated with hyperkalemia, such as cardiac arrhythmias. Choices B, C, and D are incorrect because while hemoglobin levels are relevant for assessing the effectiveness of erythropoietin therapy, monitoring potassium levels is more critical due to the potential adverse effects of elevated potassium levels in CKD patients on this therapy.
The nurse is caring for a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which laboratory value requires immediate intervention?
- A. Serum potassium of 5.5 mEq/L
- B. Serum creatinine of 2.5 mg/dL
- C. Hemoglobin of 10 g/dL
- D. White blood cell count of 10,000/mm³
Correct Answer: A
Rationale: A serum potassium level of 5.5 mEq/L is most concerning in a client receiving erythropoietin therapy as it indicates hyperkalemia, requiring immediate intervention. High potassium levels can lead to severe cardiac arrhythmias and must be addressed promptly. The other laboratory values, though abnormal, do not present immediate life-threatening risks as hyperkalemia does.