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A client with heart failure is prescribed furosemide (Lasix). Which assessment finding requires immediate intervention?
- A. Heart rate of 60 beats per minute
- B. Blood pressure of 100/60 mmHg
- C. Crackles in the lungs
- D. Presence of a new murmur
Correct Answer: C
Rationale: The correct answer is C. Crackles in the lungs indicate fluid overload, a common issue in heart failure patients. Immediate intervention is necessary to prevent worsening heart failure symptoms and potential complications. A heart rate of 60 beats per minute and a blood pressure of 100/60 mmHg are within normal ranges for many individuals and do not typically require immediate intervention in this context. The presence of a new murmur may be important to monitor but is not the priority when crackles in the lungs suggest fluid overload.
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An adult male with schizophrenia who has been noncompliant in taking oral antipsychotic medications refuses a prescribed IM medication. What action should the nurse take?
- A. Notify the healthcare provider of the client's refusal
- B. Attempt to convince the client to take the medication
- C. Administer the medication without the client's consent
- D. Document the refusal and take no further action
Correct Answer: A
Rationale: The correct action is to notify the healthcare provider of the client's refusal. It is important for the healthcare provider to be informed so that they can decide on the next steps in the client's treatment, which may involve exploring alternative options or strategies. Attempting to convince the client to take the medication may not be effective, especially if the client is refusing. Administering the medication without the client's consent would violate the client's autonomy and rights. Simply documenting the refusal without further action may not address the client's treatment needs.
The nurse is assessing a client with chronic heart failure who is receiving furosemide (Lasix). Which assessment finding is most concerning?
- A. Heart rate of 60 beats per minute
- B. Blood pressure of 110/70 mmHg
- C. Elevated liver enzymes
- D. Elevated blood glucose level
Correct Answer: C
Rationale: Elevated liver enzymes are most concerning in a client with chronic heart failure as they may indicate liver congestion or worsening heart failure, requiring immediate intervention. Elevated liver enzymes can be a sign of hepatotoxicity or liver damage, which could be a result of furosemide (Lasix) use. Monitoring liver function is crucial in patients taking furosemide due to the risk of hepatotoxicity. A heart rate of 60 beats per minute and a blood pressure of 110/70 mmHg are within normal ranges for a client with chronic heart failure. An elevated blood glucose level may be expected due to the effects of furosemide but is not as immediately concerning as elevated liver enzymes.
A client with cirrhosis is admitted with hepatic encephalopathy. Which laboratory value is most concerning?
- A. Serum ammonia level of 100 mcg/dl
- B. Bilirubin level of 3.0 mg/dl
- C. Prothrombin time of 18 seconds
- D. Serum sodium level of 135 mEq/L
Correct Answer: A
Rationale: A serum ammonia level of 100 mcg/dl is most concerning in a client with hepatic encephalopathy. Elevated serum ammonia levels indicate significant liver dysfunction and an increased risk of worsening encephalopathy. Bilirubin level and prothrombin time are important in assessing liver function, but in the context of hepatic encephalopathy, elevated ammonia levels take precedence as they directly contribute to neurological symptoms. Serum sodium level, though important, is not the primary concern when managing hepatic encephalopathy.
The nurse enters a client's room to administer scheduled daily medications and observes the client leaning forward and using pursed lip breathing. Which action is most important for the nurse to implement first?
- A. Evaluate the oxygen saturation.
- B. Administer a bronchodilator.
- C. Assist the client to sit upright.
- D. Encourage slow, deep breathing.
Correct Answer: A
Rationale: In this scenario, the nurse should first evaluate the oxygen saturation. This action is crucial as it provides immediate information on the client's respiratory status. Assessing the oxygen saturation can help determine the adequacy of oxygenation and guide further interventions. Administering a bronchodilator (Choice B) may be necessary based on assessment findings, but it should not be the first action without knowing the oxygen saturation level. While assisting the client to sit upright (Choice C) is generally beneficial for respiratory function, in this case, assessing oxygen saturation takes precedence. Encouraging slow, deep breathing (Choice D) can be helpful, but it is secondary to evaluating the oxygen saturation in this situation.
A male client with hypertension, who received new antihypertensive prescriptions at his last visit, returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106, and he admits that he has not been taking the prescribed medication because the drugs make him 'feel bad'. In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?
- A. Blindness due to cataracts
- B. Acute kidney injury due to glomerular damage
- C. Stroke secondary to hemorrhage
- D. Heart block due to myocardial damage
Correct Answer: C
Rationale: The correct answer is C, 'Stroke secondary to hemorrhage.' Uncontrolled hypertension can lead to the weakening of blood vessels in the brain, increasing the risk of a stroke due to hemorrhage. This can result in serious neurological deficits or even death. Choices A, B, and D are incorrect because while hypertension can have various complications including vision changes, kidney damage, and heart problems, the most immediate and severe risk associated with uncontrolled hypertension is a stroke from cerebral hemorrhage.