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A healthcare professional is using the I-SBAR communication tool to provide the client's provider with information about the client. The healthcare professional should convey the client's pain status in which portion of the report?
- A. Assessment
- B. Situation
- C. Background
- D. Recommendation
Correct Answer: A
Rationale: In the I-SBAR communication tool, the 'Assessment' portion is where the healthcare professional should convey the client's pain status. This section includes the current patient information, such as the client's pain level, to provide a comprehensive view of the client's condition. Choice B ('Situation') typically involves a brief summary of the client's problem or reason for the communication. Choice C ('Background') usually covers the client's medical history and background information. Choice D ('Recommendation') focuses on the healthcare professional's suggestions or requests regarding the client's care plan, which may include pain management strategies but not the current pain status.
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In a client with liver cirrhosis, which symptom would be most concerning during assessment?
- A. Jaundice
- B. Ascites
- C. Hepatomegaly
- D. Altered mental status
Correct Answer: D
Rationale: Altered mental status would be the most concerning symptom in a client with liver cirrhosis. It may indicate hepatic encephalopathy, a serious complication requiring immediate intervention. While jaundice, ascites, and hepatomegaly are common in liver cirrhosis, they do not directly correlate with the urgency and severity of hepatic encephalopathy as altered mental status does. Therefore, altered mental status takes priority for immediate attention and intervention.
A client has a new prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include?
- A. Take the medication with food.
- B. Place the tablet under your tongue and let it dissolve completely.
- C. Swallow the tablet whole with a glass of water.
- D. Chew the tablet for faster relief.
Correct Answer: B
Rationale: The correct instruction for a client prescribed nitroglycerin sublingual tablets is to place the tablet under the tongue and let it dissolve completely. This route of administration allows for rapid absorption of the medication through the oral mucosa, providing quick relief for angina symptoms. Option A, taking the medication with food, is incorrect as nitroglycerin should be taken sublingually, not with food. Option C, swallowing the tablet whole with water, is incorrect as sublingual tablets should not be swallowed whole. Option D, chewing the tablet for faster relief, is also incorrect as chewing the tablet can lead to rapid absorption and potential adverse effects rather than a controlled release for angina relief.
A nurse is planning care for a client who has hypernatremia. Which of the following actions should the nurse include in the plan of care?
- A. Infuse hypotonic IV fluids.
- B. Implement a fluid restriction.
- C. Increase sodium intake.
- D. Administer sodium polystyrene sulfonate.
Correct Answer: A
Rationale: The correct answer is to infuse hypotonic IV fluids. In hypernatremia, there is an elevated sodium concentration in the blood, and diluting it with hypotonic fluids helps to lower the sodium levels. Implementing a fluid restriction or increasing sodium intake would worsen hypernatremia by further concentrating sodium in the body. Administering sodium polystyrene sulfonate is used for treating hyperkalemia, not hypernatremia.
The nurse is preparing to administer a blood transfusion to a client. Which action should the LPN/LVN take to ensure the client's safety?
- A. Check the client's identification and blood type.
- B. Monitor the client's vital signs every hour during the transfusion.
- C. Administer the blood through a peripheral IV line.
- D. Verify the blood product with another nurse before administration.
Correct Answer: D
Rationale: To ensure the client's safety during a blood transfusion, it is crucial to verify the blood product with another nurse before administration. This step helps confirm the correct blood type and prevents transfusion reactions. While checking the client's identification and blood type (Choice A) is important, the ultimate responsibility lies with confirming the blood product before administration. Monitoring vital signs (Choice B) is necessary during a transfusion but does not directly address verifying the blood product. Administering blood through a peripheral IV line (Choice C) is a common practice but does not specifically ensure that the correct blood product is being administered, which is essential for the client's safety.
A client is admitted with a diagnosis of left-sided heart failure. Which assessment finding would be most concerning?
- A. Peripheral edema
- B. Crackles in the lungs
- C. Jugular vein distention
- D. Hepatomegaly
Correct Answer: B
Rationale: The correct answer is B: Crackles in the lungs. Crackles in the lungs indicate pulmonary congestion, a serious complication of left-sided heart failure. The presence of crackles suggests fluid accumulation in the lungs, impairing gas exchange and potentially leading to respiratory distress. Immediate intervention is necessary to prevent worsening respiratory function. Choices A, C, and D are incorrect: Peripheral edema is a common finding in heart failure but may not be as acutely concerning as pulmonary congestion. Jugular vein distention is associated with right-sided heart failure, not left-sided heart failure. Hepatomegaly is often seen in liver conditions and right-sided heart failure, not specifically left-sided heart failure.