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A nurse is caring for a client who has heart failure. Which of the following findings indicate the client is at risk for developing complications?
- A. Dysrhythmias
- B. Respiratory alkalosis
- C. Acute kidney injury
- D. Fluid volume deficit
Correct Answer: A
Rationale: The correct answer is A, dysrhythmias. In heart failure, the heart's inability to pump effectively can lead to electrical disturbances causing dysrhythmias, which can be life-threatening. Dysrhythmias can result in decreased cardiac output, further exacerbating heart failure. Respiratory alkalosis (B) is not a direct complication of heart failure. Acute kidney injury (C) can occur due to decreased cardiac output, leading to decreased renal perfusion, but it is not a direct risk factor for complications in heart failure. Fluid volume deficit (D) is a common finding in heart failure due to fluid retention, but it is not a direct risk for complications like dysrhythmias.
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A nurse is reviewing the laboratory findings of a client who has a new diagnosis of Graves' disease. The nurse should anticipate which of the following laboratory values to be elevated?
- A. Triiodothyronine
- B. Phosphorus
- C. Calcium
- D. Thyroid-stimulating hormone
Correct Answer: A
Rationale: The correct answer is A: Triiodothyronine. In Graves' disease, there is overproduction of thyroid hormones, including triiodothyronine (T3). Elevated T3 levels are characteristic due to increased thyroid hormone synthesis and release. Triiodothyronine is the active form of thyroid hormone, affecting metabolism, heart rate, and other body functions. Phosphorus (B), calcium (C), and thyroid-stimulating hormone (D) are not typically elevated in Graves' disease. Phosphorus and calcium levels may be normal or even decreased, as the disease primarily affects thyroid hormone levels. Thyroid-stimulating hormone is usually suppressed in Graves' disease due to the negative feedback mechanism of high thyroid hormone levels.
A nurse on an intensive care unit is planning care for a client who has increased intracranial pressure following a head injury. Which of the following IV medications should the nurse plan to administer?
- A. Propranolol
- B. Dobutamine
- C. Mannitol
- D. Chlorpromazine
Correct Answer: C
Rationale: The correct answer is C: Mannitol. Mannitol is an osmotic diuretic that helps reduce cerebral edema by drawing water out of brain tissue. This helps decrease intracranial pressure in clients with head injuries. Propranolol (A) is a beta-blocker used for hypertension, not specifically for intracranial pressure. Dobutamine (B) is a beta-adrenergic agonist used for cardiac support, not for intracranial pressure. Chlorpromazine (D) is an antipsychotic medication and does not address intracranial pressure. In summary, Mannitol is the appropriate choice for managing increased intracranial pressure due to its osmotic diuretic properties.
A nurse is planning care for a client who has hemiplegia. Which of the following interventions should the nurse include?
- A. Instruct the client to sit on a rubber ring when seated in a chair.
- B. Raise the head of the client's bed to a 90° angle.
- C. Place pillows between the client's knees when in a side-lying position.
- D. Use moisturizing lotion while massaging the client's bony prominences.
Correct Answer: C
Rationale: The correct answer is C: Place pillows between the client's knees when in a side-lying position. Placing pillows between the knees helps maintain proper alignment of the hips and spine, preventing the development of pressure ulcers and improving comfort for the client. Choice A is incorrect as sitting on a rubber ring does not directly address the client's hemiplegia. Choice B is incorrect because raising the head of the bed to a 90° angle may not be suitable for a client with hemiplegia due to potential issues with positioning and pressure distribution. Choice D is incorrect as using moisturizing lotion while massaging bony prominences is not a specific intervention for hemiplegia care.
A nurse is admitting a client who has arthritis pain and reports taking ibuprofen several times daily for 3 years. Which of the following tests should the nurse monitor?
- A. Serum calcium
- B. Stool for occult blood
- C. Fasting blood glucose
- D. Urine for white blood cells
Correct Answer: B
Rationale: The correct answer is B: Stool for occult blood. Long-term use of ibuprofen can lead to gastrointestinal bleeding, which may not always present with visible blood in the stool. Monitoring for occult blood helps detect this potential side effect early. Choices A, C, and D are not directly related to the adverse effects of ibuprofen use. Serum calcium is not typically affected by ibuprofen. Fasting blood glucose monitoring is more relevant for medications affecting glucose metabolism. Urine for white blood cells is not a common test for monitoring the side effects of ibuprofen.
A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation of the graft?
- A. Palpable thrill
- B. Memorantake blood pressure
- C. Absence of a bruit
- D. Dilated appearance of the graft
Correct Answer: A
Rationale: The correct answer is A: Palpable thrill. A palpable thrill indicates that there is adequate circulation of the arteriovenous graft. A thrill is a vibration felt over the graft site, which suggests that blood is flowing through the graft properly. A palpable thrill is a positive sign of good circulation.
The other choices are incorrect because:
B: Membranous blood pressure does not provide information about the circulation of the graft.
C: Absence of a bruit could indicate decreased or absent blood flow through the graft.
D: Dilated appearance of the graft does not necessarily indicate adequate circulation; it could be due to other reasons such as infection or inflammation.