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A nurse is assessing a client who has fluid overload. Which of the following findings shouldn't the nurse expect?
- A. Increased heart rate
- B. Increased blood pressure
- C. Increased respiratory rate
- D. Increased hematocrit
Correct Answer: D
Rationale: The correct answer is D: Increased hematocrit. In fluid overload, there is an excess of fluid in the body, leading to dilution of blood components including hematocrit. Therefore, an increased hematocrit would not be expected. Increased heart rate (A), blood pressure (B), and respiratory rate (C) are all common findings in fluid overload due to the body's compensatory mechanisms to maintain adequate perfusion. Thus, these findings are expected.
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A nurse is teaching self-management to a client who has hepatitis B. Which of the following instructions should the nurse include in the teaching?
- A. Limit salt intake.
- B. Avoid consuming alcohol.
- C. Engage in light exercise regularly.
- D. Rest frequently throughout the day.
Correct Answer: D
Rationale: The correct answer is D: Rest frequently throughout the day. For a client with hepatitis B, rest is essential to allow the body to recover and heal. Hepatitis B can cause fatigue and weakness, so resting frequently helps to conserve energy and support the immune system in fighting the infection. Limiting salt intake (Choice A) is not directly related to managing hepatitis B. Avoiding alcohol (Choice B) is important but more for liver health in general, not specifically for hepatitis B. Engaging in light exercise regularly (Choice C) may be beneficial for overall health, but during active hepatitis B infection, rest is more crucial.
A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?
- A. Chest pain
- B. Hypotension
- C. Generalized urticaria
- D. Fever
Correct Answer: C
Rationale: The correct answer is C: Generalized urticaria. This finding indicates an allergic transfusion reaction because urticaria, or hives, is a common symptom of an allergic response. It is caused by histamine release in response to the foreign blood product. Chest pain (A) is more indicative of a possible cardiac issue. Hypotension (B) may suggest a hemolytic reaction due to rapid destruction of red blood cells. Fever (D) is a common symptom of a febrile non-hemolytic transfusion reaction. Other choices are incorrect as they are not specific to an allergic reaction.
A nurse is caring for a client who has heart failure and a new prescription for furosemide. For which of the following adverse effects should the nurse monitor?
- A. Hypokalemia
- B. Hyperkalemia
- C. Hypernatremia
- D. Hypertension
Correct Answer: A
Rationale: The correct answer is A: Hypokalemia. Furosemide is a loop diuretic that can cause potassium loss through increased urine output. This can lead to hypokalemia, which can be dangerous in a client with heart failure as it can worsen cardiac function and lead to arrhythmias. The nurse should monitor the client's potassium levels regularly to prevent this adverse effect.
Summary of other choices:
B: Hyperkalemia - Furosemide does not typically cause hyperkalemia.
C: Hypernatremia - Furosemide is a diuretic that can lead to sodium loss, not hypernatremia.
D: Hypertension - Furosemide is actually used to treat hypertension, so it is not an adverse effect of the medication in this scenario.
A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate?
- A. Pantoprazole 80 mg IV bolus twice daily
- B. Furosemide 40 mg IV
- C. Lactulose 20 mg PO
- D. Acetaminophen 650 mg PO
Correct Answer: A
Rationale: The correct answer is A: Pantoprazole 80 mg IV bolus twice daily. In acute pancreatitis, gastric acid hypersecretion can occur, leading to exacerbation of pancreatic inflammation. Pantoprazole is a proton pump inhibitor that helps reduce gastric acid secretion, which can alleviate pancreatic irritation. IV administration ensures rapid onset of action.
B: Furosemide is a diuretic used for conditions like heart failure or edema, not indicated for acute pancreatitis.
C: Lactulose is a laxative used for hepatic encephalopathy to reduce ammonia levels, not indicated for acute pancreatitis.
D: Acetaminophen is a pain reliever, but it does not address the underlying cause of acute pancreatitis.
A nurse assesses a client in skeletal traction. What indicates infection at the pin sites?
- A. Pallor
- B. Fever
- C. Bradycardia
- D. Elevated blood pressure
Correct Answer: B
Rationale: The correct answer is B: Fever. Infection at the pin sites in skeletal traction commonly presents with systemic signs like fever. Fever is a typical response to infection as the body tries to fight off the invading pathogens. Pallor, bradycardia, and elevated blood pressure are not specific indicators of infection at pin sites. Pallor may indicate poor perfusion, bradycardia is a slow heart rate which is not typically associated with infection, and elevated blood pressure can be a response to various stressors but not a specific sign of infection at pin sites. In summary, fever is the most reliable indicator of infection at pin sites due to its systemic nature.