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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 caring for an older adult client who has rheumatoid arthritis (RA) and is taking aspirin 650 mg every 4 hours. Which of the following diagnostic tests should the nurse monitor to evaluate the effectiveness of this medication?
- A. C-reactive protein
- B. Erythrocyte sedimentation rate (ESR)
- C. White blood cell count
- D. Hematocrit
Correct Answer: B
Rationale: The correct answer is B: Erythrocyte sedimentation rate (ESR). ESR is a common test used to monitor inflammation levels in rheumatoid arthritis (RA) patients. Aspirin is an anti-inflammatory medication, so monitoring ESR can help assess the effectiveness of the treatment. A decrease in ESR levels indicates a reduction in inflammation, suggesting that the aspirin is working. The other choices (A, C, D) are not specific to monitoring the effectiveness of aspirin in RA. C-reactive protein and white blood cell count are general markers of inflammation and infection, not specific to RA. Hematocrit measures red blood cell levels, which are not directly related to the effectiveness of aspirin in treating RA.
The nurse is caring for a postoperative client who has a chest tube connected to suction and a water-seal drainage system. Which of the following indicates to the nurse that the chest tube is functioning properly?
- A. Fluctuation of the fluid level within the water seal chamber
- B. Continuous bubbling in the water seal chamber
- C. Absence of bubbling in the water seal chamber
- D. No drainage in the collection chamber
Correct Answer: A
Rationale: Fluctuation (tidaling) in the water-seal chamber during inspiration and expiration indicates the chest tube is functioning properly.
A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following actions is the nurse's highest priority?
- A. Administering a nebulized beta-adrenergic
- B. Providing supplemental oxygen
- C. Administering an intravenous corticosteroid
- D. Encouraging the client to use their inhaler
Correct Answer: A
Rationale: The correct answer is A: Administering a nebulized beta-adrenergic. This is the highest priority because it helps to rapidly dilate the bronchioles, improving airflow and oxygenation in the client. This immediate action is crucial in managing an acute asthma exacerbation and can prevent respiratory distress. Providing supplemental oxygen (B) is important but not the highest priority. Administering an intravenous corticosteroid (C) is beneficial for reducing inflammation but takes longer to take effect compared to a beta-adrenergic. Encouraging the client to use their inhaler (D) is helpful, but in an acute exacerbation, a nebulized beta-adrenergic is more effective for immediate relief.
A nurse is teaching a newly licensed nurse about the purpose of a CA 125 test. Which of the following statements should the nurse include in the teaching?
- A. A CA 125 test is used to monitor a client's progress during treatment of ovarian cancer.
- B. A CA 125 test is used to detect pregnancy.
- C. A CA 125 test is used to diagnose cervical cancer.
- D. A CA 125 test is used to screen for prostate cancer.
Correct Answer: A
Rationale: The correct answer is A: A CA 125 test is used to monitor a client's progress during treatment of ovarian cancer. This is because CA 125 is a biomarker that is commonly elevated in ovarian cancer patients. Monitoring CA 125 levels helps healthcare providers assess the effectiveness of treatment and detect any recurrence of the disease.
Choice B is incorrect because a CA 125 test is not used to detect pregnancy. Choice C is incorrect because a CA 125 test is not used to diagnose cervical cancer; it is primarily associated with ovarian cancer. Choice D is incorrect because a CA 125 test is not used to screen for prostate cancer; it is specific to ovarian cancer.
A nurse is collaborating on care for a client who has COPD. Which of the following tasks should the nurse recommend be referred to an occupational therapist for assistance?
- A. Instructing how to use kitchen tools to prepare a meal
- B. Administering oxygen therapy
- C. Monitoring oxygen saturation levels
- D. Assessing breathing patterns
Correct Answer: A
Rationale: The correct answer is A because an occupational therapist can help the client with COPD by providing strategies and adaptive tools for meal preparation to conserve energy and promote independence in daily activities. Administering oxygen therapy (B), monitoring oxygen saturation levels (C), and assessing breathing patterns (D) are within the scope of nursing practice for managing COPD. These tasks require clinical knowledge and skills that nurses are trained to perform.