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A nurse assesses a client who is prescribed a medication that stimulates beta1 receptors. Which assessment finding should alert the nurse to urgently contact the health care provider?
- A. Heart rate of 50 beats/min
- B. Respiratory rate of 18 breaths/min
- C. Oxygen saturation of 92%
- D. Blood pressure of 144/69 mm Hg
Correct Answer: A
Rationale: Stimulation of beta1 receptor sites in the heart has positive chronotropic and inotropic actions, leading to an increased heart rate and cardiac output. A heart rate of 50 beats/min indicates the client is not responding to the medication, which is a cause for concern.
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A nurse teaches a client who has been prescribed a 24-hour urine collection to measure excreted hormones. The client asks, Why do I need to collect urine for 24 hours instead of providing a random specimen? How should the nurse respond?
- A. The hormone is secreted on a circadian rhythm.
- B. The hormone is diluted in urine, therefore, we need a large volume.
- C. We are assessing when the hormone is secreted in large amounts.
- D. To collect the correct hormone, you need to urinate multiple times.
Correct Answer: A
Rationale: Hormones are secreted in a pulsatile or circadian cycle. A 24-hour urine collection provides a more accurate reflection of hormone secretion over time compared to a random specimen.
A nurse plans care for an older adult who is admitted to the hospital for pneumonia. The client has no known drug allergic status nor a significant medical history. Which action should the nurse include in this clients plan of care?
- A. Initiate Airborne Precautions.
- B. Offer fluids every hour or two.
- C. Administer broad-spectrum antibiotics.
- D. Palpate the clients thyroid gland.
Correct Answer: B
Rationale: Decreased antidiuretic hormone (ADH) production is a normal age-related change, leading to increased urine output and risk of dehydration. Offering fluids regularly helps prevent dehydration in older adults.
A nurse assesses clients who have endocrine disorders. Which assessment findings are paired correctly with the endocrine disorder? (Select all that apply.)
- A. Thyroid-stimulating hormone: Increase bone formation
- B. Melanocyte-stimulating hormone: Increase bone formation
- C. Parathyroid hormone: Synthesis and release of corticosteroids
- D. Antidiuretic hormone: Increase urinary output
- E. Parathyroid hormone: Increase bone resorption
Correct Answer: A,E
Rationale: Thyroid-stimulating hormone promotes bone formation, and parathyroid hormone increases bone resorption. Melanocyte-stimulating hormone affects pigmentation, not bone formation. Antidiuretic hormone decreases urinary output, and parathyroid hormone does not directly stimulate corticosteroid release.
A nurse cares for a client who has excessive catecholamine release. Which assessment finding should the nurse correlate with this condition?
- A. Decreased blood pressure
- B. Increased pulse
- C. Decreased respiratory rate
- D. Increased urine output
Correct Answer: B
Rationale: Catecholamines activate the sympathetic nervous system, leading to tachycardia (increased pulse) as part of the fight-or-flight response.
A nurse cares for a client who is prescribed a 24-hour urine collection. The unlicensed assistive personnel (UAP) reports that, while pouring urine into the collection container, some urine splashed his hand. Which action should the nurse take next?
- A. Ask the UAP if he washed his hands afterward.
- B. Have the UAP fill out an incident report.
- C. Ask the laboratory if the container has preservative in it.
- D. Send the UAP to Employee Health right away.
Correct Answer: A
Rationale: The nurse should ensure the UAP washed their hands to follow Standard Precautions and remove any potential preservative, which may be caustic. This is the immediate safety priority.