Nokea
A client with pneumonia is receiving intravenous (IV) antibiotics. Which assessment finding indicates that the client's condition is improving?
- A. Client's respiratory rate decreases from 24 to 20 breaths per minute
- B. White blood cell count decreases to normal range
- C. Client reports increased energy levels
- D. Cough becomes productive with green sputum
Correct Answer: B
Rationale: A decrease in white blood cell count indicates that the infection is responding to treatment and the client's condition is improving. Monitoring the white blood cell count is a more objective indicator of the body's response to the antibiotics. Choices A, C, and D may also be positive signs, but they are less specific and may vary among individuals. Respiratory rate alone may not be sufficient to indicate improvement, as other factors can influence it. Energy levels and cough characteristics are subjective and may not always correlate with the effectiveness of antibiotic treatment.
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After a thyroidectomy, which vital sign is the most important for the nurse to monitor closely?
- A. Monitor respiratory rate and rhythm.
- B. Assess for signs of hypocalcemia.
- C. Monitor for elevated body temperature.
- D. Check blood pressure every 30 minutes.
Correct Answer: B
Rationale: The correct answer is B: Assess for signs of hypocalcemia. After a thyroidectomy, monitoring for hypocalcemia is crucial because damage to the parathyroid glands during surgery can result in low calcium levels, which may cause life-threatening complications. Monitoring respiratory rate and rhythm (choice A) is important but not the most critical in this situation. Monitoring for elevated body temperature (choice C) is less of a priority post-thyroidectomy. Checking blood pressure every 30 minutes (choice D) is not as vital as monitoring for hypocalcemia in this context.
Prior to obtaining a trapeze bar for a client with limited mobility, which client assessment is most important for the nurse to obtain?
- A. Balance and coordination
- B. Cognitive status
- C. Level of pain
- D. Upper body muscle strength
Correct Answer: D
Rationale: The correct answer is D: Upper body muscle strength. The ability to use a trapeze bar requires adequate upper body strength to support the weight and facilitate repositioning. While assessing pain, coordination, and cognitive status are important, the priority is determining if the client can physically manage the trapeze bar safely. Without sufficient upper body muscle strength, the client may not be able to use the trapeze bar effectively and safely. Assessing balance and coordination is also important but secondary to ensuring the client has the required upper body strength. Cognitive status is crucial for understanding instructions related to using the trapeze bar, but it is not the most critical assessment in this scenario. Pain assessment is essential for overall care but does not directly impact the client's ability to use a trapeze bar like upper body muscle strength does.
Which meal option should the nurse recommend for a client with renal disease who is following a low-protein diet?
- A. Grilled chicken with steamed vegetables
- B. Tofu stir-fry with rice
- C. Pasta with marinara sauce
- D. Baked salmon with quinoa
Correct Answer: C
Rationale: The correct answer is C: Pasta with marinara sauce. Clients with renal disease following a low-protein diet should opt for lower-protein options. Pasta with marinara sauce is a suitable choice as it is lower in protein compared to grilled chicken, tofu, or salmon. Grilled chicken, tofu, and salmon are higher in protein content and are not ideal for individuals following a low-protein diet for renal disease as they may strain the kidneys.
A client has been receiving hydromorphone every six hours for four days. What assessment should the nurse prioritize?
- A. Increase the dosage of the medication.
- B. Auscultate bowel sounds.
- C. Monitor the client's blood pressure.
- D. Check the client's respiratory rate.
Correct Answer: B
Rationale: The correct answer is B. Hydromorphone can cause constipation, a common side effect of opioids. Therefore, it is crucial to auscultate bowel sounds to monitor for signs of decreased gastrointestinal motility. Monitoring blood pressure (choice C) and respiratory rate (choice D) are important but not the priority in this scenario as constipation is a common issue with opioid use. Increasing the dosage of the medication (choice A) is not appropriate without assessing the client's bowel function first.
A client receiving chemotherapy has severe neutropenia. What snack is best for the nurse to recommend?
- A. Baked apples with raisins.
- B. Yogurt with fresh berries.
- C. Avocados and cheese.
- D. Fresh fruit salad.
Correct Answer: B
Rationale: For a client with severe neutropenia, it is crucial to recommend a snack that is low in bacteria to reduce the risk of infection. Yogurt with fresh berries is an excellent choice as it is not only low in bacteria but also provides nutritional value. Baked apples with raisins (choice A) may not be ideal as the preparation process could introduce bacteria. Avocados and cheese (choice C) may not be the best option due to their potential bacterial content. Fresh fruit salad (choice D) may have a higher risk of bacterial contamination compared to yogurt with fresh berries.