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A client with hyperparathyroidism reports a sudden onset of severe flank pain. Which intervention should the nurse include in the client's plan of care?
- A. Implement seizure precautions.
- B. Begin straining all urine.
- C. Administer a PRN dose of a laxative.
- D. Initiate cardiac telemetry.
Correct Answer: B
Rationale: Straining urine checks for kidney stones, likely causing flank pain in hyperparathyroidism, prioritizing over other interventions.
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A client with pancreatitis is receiving 0.9% normal saline, and the prescribed IV infusion rate was increased from 100 mL/hour to 150 mL/hour. Which assessment finding indicates to the nurse that the prescription has a therapeutic outcome?
- A. An increase in the hematocrit (HCT) from 42% (0.42 volume fraction) to 52% (0.52 volume fraction).
- B. An increase in the blood glucose level from 130 mg/dl. (7.22 mmol/L).
- C. A decrease in blood urea nitrogen (BUN) from 36 mg/dL (12.9 mmol/L) to 23 mg/dL (8.21 mmol/L).
- D. A decrease in serum amylase from 24 units/dl (240 units) to 12 units/dl. (120 units/L);
Correct Answer: C
Rationale: A decrease in BUN indicates improved renal perfusion, a therapeutic outcome of increased IV fluids. Increased hematocrit suggests fluid volume deficit, increased blood glucose is undesirable, and amylase decrease is not directly related to fluid increase.
The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?
- A. Minimize intake of spicy foods.
- B. Remain upright following meals.
- C. Avoid wearing tight fitting clothes.
- D. Begin a smoking cessation program.
Correct Answer: B
Rationale: Remaining upright after meals prevents acid reflux by facilitating digestion, making it the most critical instruction for GERD management.
An adult client is admitted to the medical unit due to rectal bleeding after a colonoscopy in which a polyp was biopsied and cauterized. Which Intervention should the nurse do first?
- A. Palpate all peripheral pulses in the extremities.
- B. Encourage cough and deep breathing exercises.
- C. Complete a focused assessment of the abdomen.
- D. Initiate measurement of fluid intake and output.
Correct Answer: C
Rationale: A focused abdominal assessment determines the severity of bleeding and guides further interventions, prioritizing over pulses, respiratory exercises, or fluid monitoring.
The nurse is assessing a client who is newly diagnosed with hypothyroidism. Which assessment finding requires immediate intervention?
- A. Weight gain.
- B. Hypoventilation.
- C. Cold intolerance.
- D. Lethargy
Correct Answer: B
Rationale: Hypoventilation can lead to hypoxemia and hypercapnia, requiring immediate intervention to prevent respiratory crisis. Other symptoms are common but not immediately life-threatening.
Nurses' Notes
Assessment is completed. The nurse notes that the nail angle is 180 degrees when viewed from the side and is spongy when palpated.
The nurse reviews client data. Select the 3 possible conditions that could have the clinical manifestation of clubbed nails for this client.
- A. Pneumonia
- B. Lung cancer
- C. Flu
- D. Chronic obstructive pulmonary disease (COPD)
- E. Chronic bronchitis
Correct Answer: B,E
Rationale: Lung cancer and chronic bronchitis are associated with clubbed nails due to chronic hypoxemia, unlike pneumonia or flu.