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A healthcare professional is assessing a client with severe dehydration. Which finding indicates a need for immediate intervention?
- A. Heart rate of 110 beats per minute.
- B. Blood pressure of 90/60 mm Hg.
- C. Urine output of 20 ml/hour.
- D. Dry mucous membranes.
Correct Answer: C
Rationale: The correct answer is C: Urine output of 20 ml/hour. In severe dehydration, decreased urine output indicates compromised renal function and impaired fluid balance, necessitating immediate intervention to prevent further complications. A: Heart rate of 110 bpm is elevated but not an immediate concern. B: Blood pressure of 90/60 mm Hg is low but may be compensated in dehydration. D: Dry mucous membranes are a sign of dehydration but not an immediate threat compared to inadequate urine output.
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A client with a history of asthma is prescribed salmeterol (Serevent). Which instruction should the nurse provide?
- A. Use this medication for acute asthma attacks.
- B. Use this medication before using your albuterol inhaler.
- C. Use this medication twice daily for long-term control.
- D. Use this medication as needed for wheezing.
Correct Answer: C
Rationale: The correct instruction is C: Use this medication twice daily for long-term control. Salmeterol is a long-acting beta-agonist used for maintenance therapy in asthma to provide long-term control of symptoms and prevent exacerbations. It should not be used for acute asthma attacks as it does not provide quick relief like rescue inhalers such as albuterol (choice A). It is not meant to replace albuterol, so it should not be used before using albuterol (choice B). Using salmeterol as needed for wheezing (choice D) is not appropriate as it is a maintenance medication and not a rescue medication.
A client with heart failure is receiving digoxin (Lanoxin). Which finding indicates that the medication is effective?
- A. Increased heart rate.
- B. Decreased pedal edema.
- C. Elevated blood pressure.
- D. Improved urine output.
Correct Answer: B
Rationale: The correct answer is B: Decreased pedal edema. Digoxin is a medication commonly used to treat heart failure by improving the heart's ability to pump effectively. As the medication helps to reduce fluid buildup in the body, a decrease in pedal edema (swelling in the feet and ankles) indicates that digoxin is effectively managing the client's heart failure. Increased heart rate (A) may indicate digoxin toxicity, elevated blood pressure (C) is not a typical indicator of digoxin effectiveness, and improved urine output (D) may be a result of diuretic therapy rather than specifically digoxin efficacy in heart failure management.
A client with hyperthyroidism is prescribed propylthiouracil (PTU). Which instruction should the nurse include in the client's discharge teaching?
- A. Report any signs of infection, such as sore throat or fever, to your healthcare provider.'
- B. Increase your intake of iodine-rich foods, such as seafood and dairy products.'
- C. Take the medication on an empty stomach for better absorption.'
- D. You may experience weight gain and fatigue as side effects of the medication.'
Correct Answer: A
Rationale: The correct answer is A: "Report any signs of infection, such as sore throat or fever, to your healthcare provider." This is important because PTU can cause agranulocytosis, a serious side effect that can lead to severe infections. By reporting signs of infection early, the healthcare provider can monitor the client's blood counts and adjust treatment if necessary.
Choice B is incorrect because increasing intake of iodine-rich foods can worsen hyperthyroidism. Choice C is incorrect because PTU should be taken with food to minimize gastrointestinal side effects. Choice D is incorrect because weight gain and fatigue are not common side effects of PTU; in fact, weight loss and hyperactivity are more common.
The mental health nurse observes that a female client with delusional disorder carries some of her belongings with her because she believes that others are trying to steal them. Which nursing action will promote trust?
- A. Explain that distrust is related to feeling anxious.
- B. Initiate short, frequent contacts with the client.
- C. Explain that these beliefs are related to her illness.
- D. Offer to keep the belongings at the nurse's desk.
Correct Answer: B
Rationale: Step 1: Initiating short, frequent contacts with the client will promote trust by establishing a consistent and supportive presence.
Step 2: This approach allows the nurse to build rapport and demonstrate genuine concern for the client's well-being.
Step 3: Regular interactions can help the client feel understood and supported, leading to a more trusting relationship.
Step 4: By maintaining frequent contact, the nurse can monitor the client's well-being and provide reassurance as needed.
Step 5: This proactive approach fosters trust and a therapeutic alliance, enhancing the client's overall care experience.
When assessing a client with suspected meningitis, which finding is indicative of meningeal irritation?
- A. Brudzinski's sign
- B. Positive Babinski reflex
- C. Kernig's sign
- D. Both A and C
Correct Answer: D
Rationale: The correct answer is D, Both A and C. Brudzinski's sign and Kernig's sign are both indicative of meningeal irritation. Brudzinski's sign is when flexion of the neck causes involuntary flexion of the hip and knee. Kernig's sign is when there is resistance or pain with knee extension after hip flexion. These signs suggest inflammation of the meninges, commonly seen in meningitis. Babinski reflex (choice B) is not specific to meningitis and is related to upper motor neuron dysfunction. Therefore, the correct answer is D as it includes the two most relevant signs for meningeal irritation, while the other choices are not directly associated with this condition.