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A male client with diabetes mellitus type 2, who is taking pioglitazone PO daily, reports to the nurse the recent onset of nausea, accompanied by dark-colored urine, and a yellowish cast to his skin. What instructions should the nurse provide?
- A. Seek immediate medical assistance to evaluate the cause of these symptoms.
- B. Discontinue the medication and follow up with a healthcare provider.
- C. Increase fluid intake and monitor urine color.
- D. Continue taking the medication and report any changes.
Correct Answer: A
Rationale: The correct answer is A: 'Seek immediate medical assistance to evaluate the cause of these symptoms.' The symptoms described by the client, including nausea, dark-colored urine, and yellowish skin, are indicative of possible liver toxicity, a serious side effect of pioglitazone. Therefore, immediate medical evaluation is necessary to assess the severity of the condition and prevent further complications. Choices B, C, and D are incorrect: B advises discontinuing the medication without seeking immediate medical assistance, which could delay necessary treatment; C focuses solely on increasing fluid intake and monitoring urine color, overlooking the urgency of the situation; and D suggests continuing the medication when prompt evaluation is crucial in this scenario.
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A client with rapid respirations and audible rhonchi is admitted to the intensive care unit because of a pulmonary embolism (PE). Low-flow oxygen by nasal cannula and weight-based heparin protocol are initiated. Which intervention is most important for the nurse to include in this client's plan of care?
- A. Evaluate blood clotting factors daily.
- B. Encourage incentive spirometry use.
- C. Administer pain medication as needed.
- D. Monitor for signs of bleeding.
Correct Answer: A
Rationale: Evaluating blood clotting factors daily is crucial when a client is on heparin therapy to monitor for potential complications such as bleeding or clotting issues. This monitoring helps ensure that the heparin dose is within the therapeutic range and reduces the risk of bleeding or clotting complications. Encouraging incentive spirometry use is beneficial for preventing atelectasis and improving lung function, but in this scenario, monitoring blood clotting factors takes precedence. Administering pain medication as needed is important for the client's comfort but is not the priority in managing a pulmonary embolism. Monitoring for signs of bleeding is important due to heparin therapy, but evaluating blood clotting factors provides more specific information on the client's response to treatment.
When planning care for a 10-year-old child with pneumonia receiving oxygen at 5l/min per nasal cannula, what principle of oxygen administration should the nurse consider?
- A. Avoid administration of oxygen at high levels for extended periods.
- B. Increase oxygen flow rate if the child is still tachypneic.
- C. Reduce oxygen levels gradually after symptoms improve.
- D. Humidify the oxygen to prevent drying of mucous membranes.
Correct Answer: A
Rationale: The correct principle of oxygen administration to consider is to avoid administering oxygen at high levels for extended periods. High levels of oxygen for prolonged periods can lead to oxygen toxicity, especially in pediatric patients. Increasing the oxygen flow rate based on tachypnea may not be necessary and can potentially lead to oxygen toxicity. Gradually reducing oxygen levels after symptoms improve may compromise the child's oxygenation. While humidifying oxygen is important to prevent drying of mucous membranes, the primary concern in this case is to avoid high oxygen levels for an extended duration to prevent oxygen toxicity.
A healthcare provider is assessing a client with a history of hypertension who is currently taking a diuretic. Which assessment finding is most important to report to the healthcare provider?
- A. Potassium level of 3.2 mEq/L
- B. Blood pressure of 148/90 mmHg
- C. Pulse rate of 62 beats per minute
- D. Blood glucose level of 130 mg/dl
Correct Answer: A
Rationale: A potassium level of 3.2 mEq/L is low and places the client at risk for cardiac arrhythmias, requiring immediate intervention. Hypokalemia can result from diuretic use and can lead to serious complications such as irregular heart rhythms. Monitoring and correcting potassium levels are crucial in preventing adverse cardiac events. The other options, though important, do not pose an immediate life-threatening risk compared to the low potassium level.
The practical nurse (PN) is assigned to work with three registered nurses (RNs) who are caring for neurologically compromised clients. The client with which change in status is best to assign to the PN?
- A. Diabetic ketoacidosis with a Glasgow Coma Scale score change from 10 to 7.
- B. Myxedema coma with a blood pressure change from 80/50 to 70/40.
- C. Viral meningitis with a temperature change from 101°F to 102°F.
- D. Subdural hematoma with a blood pressure change from 150/80 to 170/60.
Correct Answer: C
Rationale: The client with viral meningitis and a temperature change is the most stable and appropriate for assignment to the PN. A change in temperature from 101°F to 102°F is not as critical as changes in Glasgow Coma Scale score, blood pressure, or wider blood pressure variations. The other clients require more complex monitoring and intervention due to their critical changes in status.
The nurse enters a client's room and observes the unlicensed assistive personnel (UAP) making an occupied bed. What action should the nurse take first?
- A. Place the side rails in an up position.
- B. Assist the UAP in turning the client.
- C. Provide instructions on proper bed-making techniques.
- D. Ask the client if they are comfortable.
Correct Answer: A
Rationale: The correct answer is to place the side rails in an up position first. This action is essential to prevent the client from falling while the bed is being made. Assisting the UAP in turning the client (Choice B) is not the immediate priority. Providing instructions on bed-making techniques (Choice C) can wait until the safety of the client is ensured. Asking the client if they are comfortable (Choice D) is important but should come after ensuring the client's safety by raising the side rails.