Nokea
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.
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The mother of a one-month-old boy born at home brings the infant to his first well-baby visit. The infant was born two weeks after his due date and is described as a 'good, quiet baby' who almost never cries. To assess for hypothyroidism, what question is most important for the nurse to ask the mother?
- A. Has your son had any immunizations yet?
- B. Is your son sleepy and difficult to feed?
- C. Are you breastfeeding or bottle-feeding your son?
- D. Were any relatives born with birth defects?
Correct Answer: B
Rationale: The correct answer is B. Excessive sleepiness and difficulty feeding can be signs of hypothyroidism in infants. Asking about the infant's sleepiness and feeding pattern is crucial in assessing for hypothyroidism. Choice A is incorrect because immunizations are not directly related to hypothyroidism. Choice C is about feeding method and not specific to hypothyroidism. Choice D is unrelated as it asks about relatives with birth defects, which does not directly assess the infant's condition.
A client is admitted with a diagnosis of sepsis. Which assessment finding is most concerning to the nurse?
- A. Temperature of 101.5°F
- B. Heart rate of 110 beats per minute
- C. Respiratory rate of 24 breaths per minute
- D. Blood pressure of 90/60 mmHg
Correct Answer: D
Rationale: A blood pressure of 90/60 mmHg in a client with sepsis is concerning for septic shock, a life-threatening condition that requires immediate intervention. Hypotension is a severe manifestation of sepsis that can lead to poor tissue perfusion and organ failure. While the other assessment findings such as an elevated temperature, increased heart rate, and respiratory rate are also common in sepsis, hypotension is particularly alarming as it indicates a critical state of shock and necessitates urgent medical attention.
Which statement by the client indicates an understanding of the dietary modifications required with Cushing syndrome?
- A. I should increase my intake of foods high in calcium.
- B. I should avoid foods with high sodium content.
- C. I need to decrease my intake of vitamin D.
- D. I should consume more potassium-rich foods.
Correct Answer: B
Rationale: The correct answer is B: 'I should avoid foods with high sodium content.' Clients with Cushing syndrome need to limit their sodium intake to help reduce fluid retention and manage hypertension, which are common complications of the syndrome. Increasing calcium intake (choice A) is not specifically indicated for Cushing syndrome. Decreasing vitamin D intake (choice C) is not a typical dietary modification for this condition. Consuming more potassium-rich foods (choice D) is not a primary focus of dietary modifications for Cushing syndrome.
The nurse is assessing a client with left-sided heart failure. Which finding should be reported to the healthcare provider immediately?
- A. Shortness of breath
- B. Jugular venous distention
- C. Crackles in the lungs
- D. Elevated liver enzymes
Correct Answer: C
Rationale: In a client with left-sided heart failure, the presence of crackles in the lungs is the most critical finding that should be reported to the healthcare provider immediately. Crackles indicate pulmonary congestion, which requires prompt intervention to prevent respiratory compromise. Shortness of breath, though a common symptom in heart failure, is a result of pulmonary congestion, making crackles a more direct indicator of the severity of the condition. Jugular venous distention and elevated liver enzymes are important to assess in heart failure but are not as immediately concerning as crackles in the lungs, which directly reflect the impact of heart failure on the respiratory system.
The nurse is preparing a 50 ml dose of 50% dextrose IV for a client with insulin shock. What is the most immediate intervention by the nurse?
- A. Dilute the dextrose in one liter of 0.9% Normal Saline solution.
- B. Mix the dextrose in a 50 ml piggyback for a total volume of 100 ml.
- C. Push the undiluted dextrose slowly through the current IV infusion.
- D. Ask the pharmacist to add the dextrose to a TPN solution.
Correct Answer: C
Rationale: The correct immediate intervention by the nurse in this situation is to push the undiluted 50% dextrose slowly through the current IV infusion. This is because in cases of insulin shock, where the client has dangerously low blood sugar levels, administering 50% dextrose directly into the bloodstream helps rapidly increase blood glucose levels. Choice A is incorrect because diluting the dextrose in one liter of normal saline would delay the administration of glucose, which is needed urgently. Choice B is incorrect as mixing the dextrose in a piggyback solution would also delay the administration of the concentrated dextrose. Choice D is incorrect because adding dextrose to a TPN solution is not the immediate intervention needed to address the low blood sugar levels in a client experiencing insulin shock.