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A nurse is caring for a client who has diabetes insipidus and is receiving desmopressin. Which of the following findings indicates the medication is effective?
- A. The client's urine output decreases.
- B. The client's blood pressure increases.
- C. The client's heart rate increases.
- D. The client's urine specific gravity decreases.
Correct Answer: A
Rationale: The correct answer is A: 'The client's urine output decreases.' Desmopressin is used to treat diabetes insipidus by reducing excessive urine output. Therefore, a decrease in urine output indicates that the medication is effectively controlling the symptoms. Choices B, C, and D are incorrect because desmopressin primarily affects urine output, not blood pressure, heart rate, or urine specific gravity.
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A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider?
- A. Increased hoarseness
- B. Serum calcium level of 8.0 mg/dL
- C. Respiratory rate of 18/min
- D. Urinary output of 60 mL in 2 hours
Correct Answer: B
Rationale: The correct answer is B: 'Serum calcium level of 8.0 mg/dL.' A low serum calcium level indicates hypocalcemia, which is a potential complication of thyroidectomy that can lead to life-threatening consequences, such as tetany or laryngospasm. Therefore, it is crucial for the nurse to report this finding promptly to the provider for timely intervention. Choices A, C, and D are important assessments following a thyroidectomy but are not as critical as detecting and addressing hypocalcemia, which can have serious implications for the client's health.
What is the best initial nursing intervention for a patient with suspected pulmonary embolism?
- A. Administer oxygen
- B. Administer anticoagulants
- C. Reposition the patient
- D. Check oxygen saturation
Correct Answer: A
Rationale: Administering oxygen is the best initial nursing intervention for a patient with suspected pulmonary embolism because it helps address hypoxia, a common complication of this condition. Oxygen therapy can improve oxygenation and support vital organ function. Administering anticoagulants (Choice B) is a treatment option for confirmed pulmonary embolism but not the initial intervention. Repositioning the patient (Choice C) and checking oxygen saturation (Choice D) are important assessments but do not address the immediate need to improve oxygenation in a patient with suspected pulmonary embolism.
What is the most appropriate intervention for a patient experiencing hypoglycemia?
- A. Administer glucagon
- B. Provide oral glucose
- C. Administer IV fluids
- D. Monitor blood sugar levels
Correct Answer: B
Rationale: Providing oral glucose is the correct intervention for a patient experiencing hypoglycemia. Oral glucose helps quickly raise blood sugar levels, making it the preferred treatment for mild hypoglycemia. Administering glucagon (Choice A) is usually reserved for severe cases when the patient cannot take anything by mouth. Administering IV fluids (Choice C) is not the primary intervention for hypoglycemia unless the patient is severely dehydrated. Monitoring blood sugar levels (Choice D) is important but providing glucose is the immediate priority to treat hypoglycemia.
What is the priority intervention for a patient with a suspected pulmonary embolism?
- A. Administer oxygen
- B. Administer anticoagulants
- C. Prepare for surgery
- D. Monitor oxygen saturation
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. Administering oxygen is the priority intervention for a patient with a suspected pulmonary embolism to improve oxygenation levels. In pulmonary embolism, there is a blockage in one of the pulmonary arteries, leading to decreased oxygen exchange. Administering oxygen helps increase oxygen saturation levels. Anticoagulants (Choice B) are essential in the treatment of pulmonary embolism but are not the initial priority intervention. Surgery (Choice C) is not typically the first-line treatment for pulmonary embolism. Monitoring oxygen saturation (Choice D) is important but administering oxygen takes precedence as the immediate action to address hypoxemia.
A nurse is providing teaching to a client who has a new prescription for warfarin. Which of the following statements indicates a need for further teaching?
- A. I will take warfarin every other day.
- B. I will eat more leafy green vegetables while taking warfarin.
- C. I will use a soft toothbrush while taking warfarin.
- D. I will have my INR checked regularly while taking warfarin.
Correct Answer: B
Rationale: The correct answer is B. Eating more leafy green vegetables can increase vitamin K intake, which may reduce the effectiveness of warfarin. This can lead to fluctuations in the International Normalized Ratio (INR) levels, affecting the medication's efficacy. Choices A, C, and D are correct statements. Taking warfarin every other day, using a soft toothbrush to prevent gum bleeding, and having regular INR checks are all appropriate and important actions when taking warfarin.