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A nurse is admitting a client who reports tightness in their chest that radiates to left arm. Which of the following findings require immediate follow-up?
- A. Temperature 37.1° C (98.8° F)
- B. Heart rate 110/min and irregular
- C. Respiratory rate 24/min
- D. Blood pressure 164/80 mm Hg
Correct Answer: B
Rationale: The correct answer is B: Heart rate 110/min and irregular. This finding indicates potential cardiac issues like myocardial infarction. Immediate follow-up is necessary to assess for any life-threatening conditions. The other options are not as urgent. A: Temperature within normal range, C: Respiratory rate slightly elevated but not critical, D: Elevated blood pressure but not as concerning as irregular heart rate.
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A nurse is caring for a client who has a history of chemotherapy-induced nausea and vomiting. Which of the following medications should the nurse administer prior to chemotherapy?
- A. Selenaline
- B. Ondansetron
- C. Diphenhydramine
- D. Methylprednisolone
Correct Answer: B
Rationale: The correct answer is B: Ondansetron. Ondansetron is a commonly used antiemetic medication that helps prevent chemotherapy-induced nausea and vomiting by blocking serotonin receptors in the gastrointestinal tract and chemoreceptor trigger zone. Administering ondansetron before chemotherapy can effectively reduce the incidence of these side effects. Selenaline (A) is not a recognized medication for managing chemotherapy-induced nausea and vomiting. Diphenhydramine (C) is an antihistamine that may be used for other types of nausea but is not the first-line treatment for chemotherapy-induced nausea. Methylprednisolone (D) is a corticosteroid that may be used to reduce inflammation but is not typically used as a primary antiemetic for chemotherapy-induced nausea and vomiting.
A home health nurse is assessing a client who has pernicious anemia. Which of the following is an expected manifestation that poses a risk to the client's safety?
- A. Loss of hearing
- B. Paresthesia
- C. Muscle wasting
- D. Changes in vision
Correct Answer: B
Rationale: The correct answer is B: Paresthesia. Pernicious anemia leads to Vitamin B12 deficiency, causing nerve damage and paresthesia (tingling or burning sensation). This poses a risk to the client's safety as it can affect their balance and coordination, increasing the risk of falls and injuries. Loss of hearing (A), muscle wasting (C), and changes in vision (D) are potential manifestations of pernicious anemia but do not directly pose a risk to safety like paresthesia.
A nurse working in an outpatient clinic is planning a community education program about reproductive cancers. The nurse should identify which of the following manifestations as a possible indication of cervical cancer?
- A. Abnormal vaginal bleeding
- B. Frequent diarrhea
- C. Urinary hesitancy
- D. Unexplained weight gain
Correct Answer: A
Rationale: The correct answer is A: Abnormal vaginal bleeding. This is a possible indication of cervical cancer because it can be a symptom of cervical dysplasia or cervical cancer. Bleeding between periods, after intercourse, or post-menopausal bleeding may indicate cervical cancer. Frequent diarrhea (B), urinary hesitancy (C), and unexplained weight gain (D) are not typically associated with cervical cancer. Diarrhea and urinary hesitancy are more commonly linked to gastrointestinal or urinary issues, while unexplained weight gain may be indicative of hormonal imbalances or other health conditions unrelated to cervical cancer.
A nurse is preparing to administer fresh frozen plasma to a client. Which of the following actions should the nurse take?
- A. Administer the transfusion through a 25-gauge saline lock.
- B. Hold the transfusion if the client is actively bleeding.
- C. Administer the plasma immediately after thawing.
- D. Transfuse the plasma over 4 hr.
Correct Answer: C
Rationale: The correct answer is C: Administer the plasma immediately after thawing. Fresh frozen plasma should be administered promptly after thawing to ensure optimal effectiveness and prevent clotting. Delaying administration can lead to decreased clotting factor activity. Choice A is incorrect as a larger gauge needle is typically used for plasma transfusions. Choice B is incorrect because fresh frozen plasma is often indicated for bleeding disorders, so holding the transfusion would be counterproductive. Choice D is incorrect as fresh frozen plasma is usually infused rapidly, not over 4 hours.
A nurse is caring for a client who is experiencing an exacerbation of heart failure. Which of the following findings indicate potential improvement?
- A. Hgb 8.4 g/dL (12 to 18 g/dL)
- B. Hct 42% (37% to 47%)
- C. WBC count 9
- D. Potassium 4.3 mEq/L (3.5 to 5 mEq/L)
Correct Answer: D
Rationale: The correct answer is D: Potassium 4.3 mEq/L (3.5 to 5 mEq/L). In heart failure exacerbation, potassium levels can be affected due to medications or fluid shifts. A potassium level within the normal range indicates electrolyte balance, which is crucial for cardiac function. Hemoglobin (Choice A) and hematocrit (Choice B) are indicators of oxygen-carrying capacity and volume status, not directly related to heart failure improvement. White blood cell count (Choice C) is not specific to heart failure exacerbation. Therefore, the correct answer is D as it reflects a positive change in electrolyte balance, essential for cardiac function.