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 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 providing discharge teaching to a client who is recovering from a sickle cell crisis. Which of the following instructions should the nurse include?
- A. Limit fluids to 1.5 L per day
- B. Avoid extremely hot or cold temperatures
- C. Avoid getting a flu vaccination
- D. Limit alcohol intake to one drink per day
Correct Answer: B
Rationale: The correct answer is B: Avoid extremely hot or cold temperatures. This instruction is important for a client recovering from a sickle cell crisis because extreme temperatures can trigger vaso-occlusive episodes. Sickle cell disease causes red blood cells to become rigid and sticky, leading to blockages in blood vessels, which can be exacerbated by temperature extremes. Limiting exposure to extreme temperatures can help reduce the risk of complications.
A: Limiting fluids is not the priority in this situation. Adequate hydration is important to prevent dehydration and maintain blood flow.
C: Getting a flu vaccination is actually recommended for clients with sickle cell disease, as they are at higher risk of complications from the flu.
D: Limiting alcohol intake is generally advisable, but it is not the most crucial instruction for someone recovering from a sickle cell crisis.
A nurse is assessing a client who has anorexia. Which of the following findings should the nurse identify as a manifestation of malnutrition?
- A. Oily skin
- B. Alopecia
- C. Increased salivation
- D. Diplopia
Correct Answer: B
Rationale: The correct answer is B: Alopecia. Alopecia, or hair loss, is a common manifestation of malnutrition due to inadequate intake of essential nutrients. Malnutrition can lead to hair thinning and loss. Oily skin (A) is more commonly associated with excess intake of fats. Increased salivation (C) is not a typical manifestation of malnutrition. Diplopia (D), or double vision, is not directly related to malnutrition.
A nurse is assessing a client who is postoperative following a transurethral resection of the prostate and is receiving continuous bladder irrigation. The client reports bladder spasms, and the nurse notes a scant amount of fluid in the urinary drainage bag, which of the following actions should the nurse take?
- A. Encourage the client to unseat every 2 hr
- B. Apply a cold compress to the suprapubic area
- C. Secure the urinary catheter to the upper left quadrant of the clients abdomen
- D. Use 0.9% sodium chloride to perform an intermittent bladder irrigation
Correct Answer: D
Rationale: The correct answer is D: Use 0.9% sodium chloride to perform an intermittent bladder irrigation. In this scenario, the client is experiencing bladder spasms and a scant amount of fluid in the drainage bag, indicating a potential blockage or clot in the catheter. Performing an intermittent bladder irrigation with 0.9% sodium chloride can help to clear the catheter and improve urine flow. This intervention helps prevent further complications such as urinary retention or infection. Encouraging the client to unseat or applying a cold compress may not address the underlying issue of catheter blockage. Securing the catheter to the upper left quadrant does not directly address the current problem and may not improve urine flow.
A nurse is caring for a client who has left-sided heart failure. Which of the following manifestations should the nurse expect?
- A. Pedal edema
- B. Enlarged liver
- C. Dyspnea
- D. Neck vein distention
Correct Answer: C
Rationale: The correct answer is C: Dyspnea. Left-sided heart failure typically results in pulmonary congestion, leading to symptoms like dyspnea due to fluid accumulation in the lungs. Pedal edema (A) is more common in right-sided heart failure. Enlarged liver (B) is a sign of right-sided heart failure as well. Neck vein distention (D) is indicative of right-sided heart failure due to increased right atrial pressure. The focus in left-sided heart failure is on pulmonary symptoms, making dyspnea the most relevant manifestation.