Nokea
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 16/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. A decrease in blood pressure indicates that the medication is effective in controlling hypertension. This is the desired outcome of telmisartan therapy as it helps reduce the risk of cardiovascular events. Choices A, C, and D are not directly related to the effectiveness of telmisartan. Blood glucose level and urinary output are not typically influenced by telmisartan, and respiratory rate is not a primary indicator of its effectiveness. Therefore, the most appropriate indicator of telmisartan's effectiveness in this scenario is a decrease in blood pressure.
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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: D
Rationale: The correct answer is D: Dyspnea. In left-sided heart failure, the heart is unable to pump efficiently, leading to a decrease in cardiac output. Dyspnea (shortness of breath) occurs due to the accumulation of fluid in the lungs (pulmonary congestion), indicating decreased cardiac output. Weight gain (A) and distended abdomen (B) are more indicative of right-sided heart failure. Confusion (C) can be a sign of decreased cerebral perfusion, but dyspnea is a more direct indicator of decreased cardiac output in left-sided heart failure.
A nurse is caring for a client who has systemic lupus erythematosus. During assessment, which of the following should the nurse expect to find?
- A. Joint inflammation
- B. Bull's eye lesion
- C. Esophagitis
- D. Tophi
Correct Answer: A
Rationale: The correct answer is A: Joint inflammation. Systemic lupus erythematosus commonly affects the joints, leading to inflammation and pain. This is known as lupus arthritis. Other choices are incorrect: B (Bull's eye lesion) is associated with Lyme disease, C (Esophagitis) is inflammation of the esophagus which is not a common manifestation of lupus, and D (Tophi) are uric acid crystal deposits seen in gout, not lupus.
A nurse is preparing to receive a client from surgery following a transverse colon resection with colostomy placement. The nurse should expect to assess the stoma at which of the following locations? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
- A. A
- B. B
- C. C
Correct Answer:
Rationale: Correct Answer: B
Rationale: The correct location to assess the stoma following a transverse colon resection with colostomy placement is at location B, which is in the left lower quadrant. This is because the transverse colon is typically located in the upper abdomen, and the stoma would be brought out at the most dependent portion of the colon, which is in the left lower quadrant. Assessing the stoma in this location allows the nurse to monitor for proper stoma function and potential complications.
Summary:
A: Incorrect - Location A is in the right upper quadrant, which is not the typical site for a stoma following a transverse colon resection.
C: Incorrect - Location C is in the left upper quadrant, which is also not the typical site for a stoma after this surgery.
D, E, F, G: Not applicable as they are not relevant to the question.
A nurse is planning care for a client who has a cervical spine injury and has a halo traction device in place. Which of the following actions should the nurse plan to take?
- A. Apply medicated powder under the vest to reduce itching
- B. Move the client up and down in bed by holding onto the halo traction device
- C. Ensure that there is space for one finger to fit between the vest and the client's skin
- D. Loosen or tighten the screws on the device as needed for the client's comfort
Correct Answer: C
Rationale: The correct answer is C: Ensure that there is space for one finger to fit between the vest and the client's skin. This is crucial to prevent pressure ulcers and skin breakdown. Tight fitting of the vest can lead to skin irritation and compromised circulation. A: Applying medicated powder can cause skin irritation and infection. B: Moving the client by holding onto the halo device can cause injury and dislodgement. D: Loosening or tightening screws without proper training can lead to complications.
A nurse is providing discharge teaching to a client who reports that they cannot afford their prescribed medication. Which of the following statements should the nurse make?
- A. I can arrange for a social worker to talk to you before you leave.
- B. I can contact the occupational therapist to schedule a home visit.
- C. Contact your pharmacy to inquire about a different medication.
- D. You should ask your provider to prescribe a cheaper medication.
Correct Answer: A
Rationale: The correct answer is A because the nurse should address the client's financial concerns by offering a social worker to assist with resources. This option demonstrates holistic care and supports the client's well-being beyond the medical aspect. Option B is irrelevant as it does not address the medication affordability issue. Option C puts the burden on the client to find a solution. Option D is not appropriate as the client may not feel comfortable asking for a cheaper medication directly.