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A female client reports that she drank a liter of a solution to cleanse her intestines but vomited immediately. How many ml of fluid intake should the nurse document?
- A. 240 ml
- B. 500 ml
- C. 760 ml
- D. 1000 ml
Correct Answer: C
Rationale: The correct answer is 760 ml. After vomiting 240 ml (1 cup), the nurse should document the remaining 760 ml as the fluid intake. Choice A (240 ml) is the amount vomited, not the total intake. Choice B (500 ml) and Choice D (1000 ml) are the total intake, not considering the vomiting.
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A client with diabetes mellitus is admitted with a blood glucose level of 600 mg/dl and is unresponsive. Which intervention should the nurse implement first?
- A. Administer 50% dextrose IV push
- B. Administer IV fluids as prescribed
- C. Check the client's blood glucose level
- D. Prepare the client for immediate dialysis
Correct Answer: B
Rationale: Administering IV fluids as prescribed should be the first intervention for a client with diabetes mellitus admitted with a blood glucose level of 600 mg/dl and unresponsive. This intervention is crucial in managing hyperglycemia by helping to correct dehydration and electrolyte imbalances. Administering 50% dextrose IV push (Choice A) would worsen hyperglycemia in this scenario. Checking the client's blood glucose level (Choice C) is important but not the priority when dealing with an unresponsive client with severe hyperglycemia. Immediate dialysis preparation (Choice D) is not indicated as the first intervention for hyperglycemia.
A client with liver cirrhosis and severe ascites has a serum sodium level of 115 mEq/L and is receiving 3% saline IV. Which assessment finding indicates that the nurse should notify the healthcare provider?
- A. The client's serum sodium level is now 130 mEq/L
- B. The client reports a headache and has a BP of 140/90
- C. The client reports shortness of breath and has an O2 saturation of 92%
- D. The client has crackles in both lung bases and an increased respiratory rate.
Correct Answer: D
Rationale: The presence of crackles in both lung bases and an increased respiratory rate indicates fluid overload, which can be exacerbated by hypertonic saline. This condition can worsen the client's respiratory status and lead to further complications. The other options do not directly relate to the fluid overload caused by the hypertonic saline. A serum sodium level of 130 mEq/L is within a normal range for treatment. A headache and a blood pressure of 140/90 are not specific indicators of worsening condition related to hypertonic saline. Shortness of breath and an O2 saturation of 92% could be related to other factors in a client with liver cirrhosis and ascites.
Progressive kyphoscoliosis leading to respiratory distress is evident in a client with muscular dystrophy. Which finding warrants immediate intervention by the nurse?
- A. Extremity muscle weakness.
- B. Bilateral eyelid drooping.
- C. Inability to swallow pills.
- D. Evidence of hypoventilation.
Correct Answer: D
Rationale: The correct answer is D: Evidence of hypoventilation. In a client with muscular dystrophy and progressive kyphoscoliosis, hypoventilation indicates respiratory muscle weakness and can lead to life-threatening respiratory distress. Immediate intervention is crucial to prevent complications. Choices A, B, and C are incorrect because while extremity muscle weakness, bilateral eyelid drooping, and inability to swallow pills are concerning symptoms in muscular dystrophy, evidence of hypoventilation poses a more immediate threat to the client's respiratory status.
The nurse is caring for a client with a history of atrial fibrillation who is receiving warfarin (Coumadin). Which laboratory value should be closely monitored?
- A. Serum potassium level
- B. Prothrombin time (PT)
- C. International Normalized Ratio (INR)
- D. Serum sodium level
Correct Answer: C
Rationale: The correct answer is C, International Normalized Ratio (INR). The INR should be closely monitored in a client receiving warfarin (Coumadin) to assess the effectiveness and safety of anticoagulation therapy. Monitoring the INR helps ensure that the client is within the therapeutic range for anticoagulation to prevent complications such as bleeding or clotting. Choices A, B, and D are incorrect. While monitoring electrolyte levels like serum potassium and sodium is important in overall client care, they are not specific to monitoring the effects of warfarin therapy. Prothrombin time (PT) is a component of INR and helps in monitoring warfarin therapy, but INR gives a standardized result that is independent of the laboratory method used, making it the preferred choice for monitoring warfarin therapy.
A female client is admitted with end-stage pulmonary disease, is alert, oriented, and complaining of shortness of breath. The client tells the nurse that she wants 'no heroic measures' taken if she stops breathing, and she asks the nurse to document this in her medical record. What action should the nurse implement?
- A. Ask the client to discuss 'do not resuscitate' with her healthcare provider
- B. Document the client's wishes in her medical record
- C. Ask the client to sign an advance directive
- D. Place a 'Do Not Resuscitate' (DNR) order in the client's chart
Correct Answer: A
Rationale: The correct action for the nurse to implement is to ask the client to discuss 'do not resuscitate' (DNR) wishes with her healthcare provider. This is important to ensure that the client makes informed decisions regarding her care. While documenting the client's wishes in her medical record is essential, it is crucial that the client discusses these wishes with the healthcare provider to understand the implications and have the DNR order legally documented. Asking the client to sign an advance directive is premature without a detailed discussion with the healthcare provider. Placing a 'Do Not Resuscitate' (DNR) order in the client's chart should only be done after the client has discussed and agreed upon this decision with the healthcare provider.