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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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The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which clinical 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: Use of accessory muscles. In a client with COPD receiving supplemental oxygen, the use of accessory muscles is a critical finding that requires immediate intervention. This observation indicates increased work of breathing, suggesting respiratory distress. Addressing this issue promptly is crucial to prevent further respiratory compromise. Choice A, oxygen saturation of 90%, is slightly below the normal range but may not require immediate intervention unless it continues to decrease. Choice B, a respiratory rate of 24 breaths per minute, is within normal limits for an adult and does not indicate an urgent issue. Choice D, inspiratory crackles, may be present in COPD due to secretions or inflammation but do not necessitate immediate intervention unless associated with other concerning signs.
A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear results are negative. What information should the nurse include in the client's teaching plan?
- A. Further evaluation involving surgery may be needed
- B. A pelvic exam is also needed before cancer is ruled out
- C. Pap smear evaluation should be continued every six months
- D. One additional negative Pap smear in six months is needed
Correct Answer: A
Rationale: In a 60-year-old female client with a family history of ovarian cancer and an abdominal mass, further evaluation involving surgery may be needed to rule out ovarian cancer. The presence of an abdominal mass raises suspicion for a possible malignancy, and a negative Pap smear result does not rule out ovarian cancer. A pelvic exam alone may not provide sufficient information to confirm or rule out ovarian cancer. Continuing Pap smear evaluations every six months or waiting for one additional negative Pap smear in six months is not appropriate in this scenario, as the abdominal mass requires immediate attention and further evaluation.
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.
The nurse is caring for a client who is postoperative following a thyroidectomy. Which assessment finding is most concerning?
- A. Slight difficulty swallowing
- B. Hoarse voice
- C. Positive Chvostek's sign
- D. Pain at the incision site
Correct Answer: C
Rationale: A positive Chvostek's sign is the most concerning assessment finding as it suggests hypocalcemia, which is a potential complication following thyroidectomy. Hypocalcemia can lead to serious complications such as tetany and laryngospasm. Immediate intervention is required to prevent further complications. Choices A, B, and D are common post-thyroidectomy findings and are expected during the immediate postoperative period. Slight difficulty swallowing may be due to postoperative swelling, a hoarse voice may be temporary due to intubation trauma, and pain at the incision site is normal after surgery.
A newly graduated female staff nurse requests reassignment to another client because a male client is asking her for a date and making suggestive comments. Which response is best for the nurse manager to provide?
- A. I have to call the supervisor to get someone else to transfer to this unit to care for him.
- B. I know you are a good nurse and can handle this client in a professional manner.
- C. I'll talk to the client about his behavior and insist that he stop it immediately.
- D. I'll change your assignment, but let's talk about how a nurse should respond to this kind of client.
Correct Answer: D
Rationale: The best response for the nurse manager to provide in this situation is option D, which involves changing the assignment to address the nurse's immediate concern. It also offers an opportunity to have a conversation with the nurse about how to professionally handle such situations in the future. Option A is not the best response as it does not address the underlying issue and simply shifts the problem to another staff member. Option B, while supportive, does not actively address the client's inappropriate behavior. Option C is not ideal as the nurse manager should handle discussions about inappropriate behavior with clients themselves rather than delegating it to the staff nurse.