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A nurse is caring for a client who has heart failure and is receiving a continuous IV infusion of furosemide. Which of the following findings indicates the nurse should increase the client's infusion rate?
- A. Urine output of 20 mL/hr
- B. Heart rate of 90/min
- C. Sodium level of 138 mEq/L
- D. Weight gain of 1 kg in 24 hr
Correct Answer: D
Rationale: A weight gain of 1 kg in 24 hours can indicate fluid retention and worsening heart failure, requiring an increase in diuresis. This finding suggests that the current diuretic therapy is not effective enough to manage the fluid overload, necessitating an increase in the infusion rate of furosemide. Choices A, B, and C are not directly related to the need for an increase in diuretic therapy in heart failure patients. Urine output of 20 mL/hr, a heart rate of 90/min, and a sodium level of 138 mEq/L are important parameters to monitor but do not specifically indicate the need to increase the infusion rate of furosemide.
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A nurse is reviewing the medical record of a client who is receiving heparin to treat deep vein thrombosis (DVT). Which of the following findings should the nurse report to the provider?
- A. aPTT of 38 seconds
- B. Hemoglobin of 15 g/dL
- C. Platelet count of 80,000/mm3
- D. INR of 1.0
Correct Answer: C
Rationale: A platelet count of 80,000/mm3 is below the normal range and should be reported to the provider due to the risk of bleeding. Heparin can cause a rare but serious side effect known as heparin-induced thrombocytopenia, leading to a decrease in platelet count and an increased risk of bleeding. The aPTT of 38 seconds, hemoglobin of 15 g/dL, and an INR of 1.0 are within normal ranges and not directly concerning in this scenario. Platelet count is crucial to monitor in clients receiving heparin therapy to ensure adequate clotting function and prevent bleeding complications.
A nurse is reviewing the laboratory results of a client who has hypocalcemia. Which of the following findings should the nurse expect?
- A. Positive Trousseau's sign
- B. Increased deep tendon reflexes
- C. Hyperactive bowel sounds
- D. Weak, thready pulse
Correct Answer: A
Rationale: A positive Trousseau's sign is a key finding in clients with hypocalcemia, indicating neuromuscular irritability. The other choices are not typically associated with hypocalcemia. Increased deep tendon reflexes are more indicative of hypercalcemia. Hyperactive bowel sounds can be seen in hyperactive bowel conditions or diarrhea, not specifically related to hypocalcemia. A weak, thready pulse may indicate cardiovascular issues, such as dehydration, but it is not a typical finding in hypocalcemia.
A nurse is providing teaching to a client who has diabetes mellitus and a new prescription for insulin glargine. Which of the following instructions should the nurse include?
- A. You should inject this medication once a day, at the same time each day.
- B. You should expect your blood glucose level to increase immediately after administration.
- C. You should rotate injection sites between your abdomen and thigh.
- D. You should inject this medication with your meals.
Correct Answer: A
Rationale: The correct instruction that the nurse should include is to inject insulin glargine once a day, at the same time each day. Insulin glargine is a long-acting insulin that provides a consistent level of insulin over 24 hours, helping to maintain stable blood glucose levels. Option B is incorrect because insulin glargine does not cause an immediate increase in blood glucose levels. Option C is important for preventing lipodystrophy but is not specific to insulin glargine administration. Option D is incorrect because insulin glargine is typically administered at the same time each day, regardless of meals.
A nurse is teaching a client who has a new prescription for alendronate. Which of the following client statements indicates an understanding of the teaching?
- A. I should take this medication at bedtime to prevent drowsiness.
- B. I should take this medication with a full glass of water before breakfast.
- C. I should avoid taking this medication with dairy products.
- D. I should remain upright for at least 30 minutes after taking this medication.
Correct Answer: B
Rationale: The correct answer is B. Alendronate should be taken with a full glass of water before breakfast to prevent esophageal irritation and improve absorption. Choice A is incorrect as alendronate is not associated with causing drowsiness. Choice C is incorrect because alendronate can be taken with or without food, so avoiding dairy products is not necessary. Choice D is incorrect as the recommended time to remain upright after taking alendronate is 30 minutes to 1 hour, not just 30 minutes.
A nurse is caring for a client who has a new diagnosis of rheumatoid arthritis. Which of the following laboratory findings should the nurse expect?
- A. Increased WBC count.
- B. Decreased hemoglobin.
- C. Decreased platelet count.
- D. Positive rheumatoid factor.
Correct Answer: D
Rationale: The correct answer is D: Positive rheumatoid factor. A positive rheumatoid factor is a common laboratory finding in clients with rheumatoid arthritis, indicating an autoimmune response. Option A, increased WBC count, is not typically associated with rheumatoid arthritis. Option B, decreased hemoglobin, and option C, decreased platelet count, are not specific laboratory findings for rheumatoid arthritis.