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A nurse is assessing a client who is taking telmisartan. The nurse should identify that which of the following findings indicates that the medication has been effective?
- A. Blood glucose of 110 mg/dL
- B. Decrease in blood pressure
- C. Increase in urinary output
- D. Respiratory rate of 10/min
Correct Answer: B
Rationale: The correct answer is B: Decrease in blood pressure. Telmisartan is an angiotensin II receptor blocker used to treat hypertension by lowering blood pressure. Therefore, a decrease in blood pressure would indicate that the medication has been effective. Choice A, blood glucose of 110 mg/dL, is unrelated to the action of telmisartan. Choice C, increase in urinary output, is not a direct effect of telmisartan. Choice D, respiratory rate of 10/min, is not a typical indicator of the effectiveness of telmisartan in managing hypertension.
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A nurse is caring for a client who has moderate Alzheimer's disease. During weekly home visits, the nurse notices that the client's caregiver is tired, irritable, and impatient with the client. Which of the following actions should the nurse recommend to the caregiver?
- A. Pursue local protective services.
- B. Consider respite care services.
- C. Take a nonprescription sleeping medication.
- D. Contact hospice services for end-of-life care.
Correct Answer: B
Rationale: The correct answer is B: Consider respite care services. Respite care provides temporary relief to caregivers, allowing them to take a break from their caregiving responsibilities. This is important for the caregiver's well-being and can prevent burnout. It also ensures the client receives continuous care. Pursuing local protective services (A) may escalate the situation unnecessarily. Taking nonprescription sleeping medication (C) is not a long-term solution and may have adverse effects. Contacting hospice services for end-of-life care (D) is premature and not appropriate for a client with moderate Alzheimer's disease.
A nurse is caring for a client who has left-sided heart failure. Which of the following findings should indicate to the nurse that the client is experiencing a decrease in cardiac output?
- A. Weight gain
- B. Distended abdomen
- C. Confusion
- D. Dyspnea
Correct Answer: C
Rationale: The correct answer is C: Confusion. In left-sided heart failure, decreased cardiac output can lead to decreased perfusion to the brain, resulting in confusion. Weight gain (A) is more indicative of fluid retention, distended abdomen (B) is a sign of ascites or abdominal organ enlargement, and dyspnea (D) is a common symptom of heart failure but not a direct indicator of decreased cardiac output.
A nurse is assessing the pain status of a group of clients. Which of the following findings indicates a client is experiencing referred pain?
- A. A client who has peritonitis reports generalized abdominal pain.
- B. A client who has angina reports substernal chest pain.
- C. A client who is postoperative reports incisional pain.
- D. A client who has pancreatitis reports pain in the left shoulder.
Correct Answer: D
Rationale: Referred pain is pain perceived at a site different from its point of origin. In the case of pancreatitis, pain is often referred to the left shoulder due to shared nerve pathways. The other choices involve pain directly related to the affected area (peritonitis, angina, postoperative incision), making them incorrect.
A nurse is reviewing the medical record of a client who has acute gout. The nurse should expect an increase in which of the following laboratory results?
- A. Chloride level
- B. Creatinine kinase
- C. Uric acid
- D. Intrinsic factor
Correct Answer: C
Rationale: The correct answer is C: Uric acid. In acute gout, there is an increase in uric acid levels due to the deposition of urate crystals in the joints, causing inflammation and pain. Elevated uric acid levels are a hallmark of gout.
A: Chloride level is not directly related to acute gout.
B: Creatinine kinase is a marker of muscle damage, not specific to gout.
D: Intrinsic factor is related to vitamin B12 absorption, not gout.
Therefore, the nurse should expect an increase in uric acid levels as the most appropriate laboratory result in a client with acute gout.
A nurse is providing teaching for a client who has diabetes mellitus about the self-administration of insulin. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will draw up the regular insulin into the syringe first.
- B. I will shake the NPH vial vigorously before drawing up the insulin.
- C. I will store prefilled syringes in the refrigerator with the needle pointed downward.
- D. I will insert the needle at a 15-degree angle.
Correct Answer: A
Rationale: Correct Answer: A - "I will draw up the regular insulin into the syringe first."
Rationale: Drawing up regular insulin before NPH prevents contamination. Regular insulin has a clear appearance, making it easier to detect any contamination. Drawing up NPH first can cause regular insulin to be contaminated if the same syringe is used. This statement demonstrates an understanding of the importance of preventing contamination and following proper insulin administration technique.
Summary of Incorrect Choices:
B: Shaking the NPH vial vigorously can cause air bubbles, affecting the accuracy of the dose.
C: Storing prefilled syringes in the refrigerator with the needle downward can cause leakage or contamination.
D: Inserting the needle at a 15-degree angle may not be appropriate for insulin injection, which typically requires a 90-degree angle for subcutaneous administration.