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A client with heart failure reports nausea, vomiting, yellow vision, and palpitations. What should the nurse assess first?
- A. Administer antiemetics to reduce nausea.
- B. Obtain a list of the client's cardiac medications.
- C. Perform an ECG to evaluate heart function.
- D. Review the client's dietary intake for possible causes.
Correct Answer: B
Rationale: The combination of nausea, vomiting, yellow vision, and palpitations in a heart failure patient is indicative of digoxin toxicity. The nurse should first obtain a list of the client's medications to verify if they are taking digoxin.
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A client with chronic kidney disease is prescribed a low-potassium diet. Which food should the nurse instruct the client to avoid?
- A. Carrots
- B. White bread
- C. Bananas
- D. Apples
Correct Answer: C
Rationale: The correct answer is C: Bananas. Bananas are high in potassium and should be avoided in clients who are on a low-potassium diet due to chronic kidney disease. Foods like apples and white bread are low in potassium and are safer choices. Carrots are also low in potassium and do not need to be avoided in this case.
The nursing student is discussing with a preceptor the delegation of tasks to an unlicensed assistive personnel (UAP). Which tasks, delegated to a UAP, indicates the student needs further teaching about the delegation process?
- A. Assist a client post cerebral vascular accident to ambulate
- B. Feed a 2-year-old in balanced skeletal traction
- C. Care for a client with discharge orders
- D. Collect a sputum specimen for acid-fast bacillus
Correct Answer: C
Rationale: Caring for a client with discharge orders involves tasks that require critical thinking and clinical judgment, which are beyond the scope of a UAP. Delegating this task to a UAP can compromise patient safety and outcomes. The correct answer is C. Choices A, B, and D are appropriate tasks to delegate to a UAP based on their training and scope of practice. Assisting a client to ambulate, feeding a pediatric patient in traction, and collecting a sputum specimen are tasks that can be safely performed by a UAP under appropriate supervision.
The client with a below-the-knee amputation is being taught about proper care of the residual limb. The most important point to emphasize would be
- A. Wrap the stump with an elastic bandage to prevent swelling
- B. Keep the skin on the stump clean and dry
- C. Use alcohol to cleanse the stump daily
- D. Apply moisturizing lotion to the stump daily
Correct Answer: B
Rationale: The correct answer is B: Keep the skin on the stump clean and dry. This is crucial for preventing infection and promoting healing of the residual limb. Wrapping the stump with an elastic bandage can constrict blood flow and cause issues. Using alcohol to cleanse the stump daily can be too harsh and drying for the skin, leading to irritation. Applying moisturizing lotion daily is not as essential as keeping the skin clean and dry to prevent complications.
A client with chronic kidney disease is prescribed erythropoietin. What lab value should the nurse monitor to evaluate the effectiveness of the therapy?
- A. White blood cell count.
- B. Hemoglobin level.
- C. Serum creatinine level.
- D. Platelet count.
Correct Answer: B
Rationale: Erythropoietin therapy stimulates red blood cell production in clients with chronic kidney disease. Hemoglobin levels should be monitored to assess the effectiveness of the therapy and ensure the client is not developing anemia. Increased hemoglobin levels indicate successful treatment, whereas very high levels may suggest erythropoietin is overcorrecting the anemia. Monitoring the white blood cell count is not directly related to erythropoietin therapy for anemia. Serum creatinine level is used to assess kidney function rather than the effectiveness of erythropoietin therapy. Platelet count is not typically affected by erythropoietin therapy and is not a key indicator of its effectiveness.
A client with a venous leg ulcer is receiving compression therapy. What assessment finding requires immediate intervention?
- A. Decreased pain and increased redness around the ulcer.
- B. Increased serous drainage from the ulcer site.
- C. Cool extremities and weak peripheral pulses.
- D. Pitting edema around the ulcer site.
Correct Answer: C
Rationale: The correct answer is C. Cool extremities and weak peripheral pulses indicate compromised circulation, possibly due to inadequate arterial blood supply. This finding requires immediate intervention to prevent further complications such as tissue damage or non-healing ulcers. Option A, decreased pain and increased redness, can be a sign of improving wound condition. Option B, increased serous drainage, may indicate a normal part of the healing process. Option D, pitting edema, is common in venous leg ulcers and may not require immediate intervention unless severe and accompanied by other concerning symptoms.