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A nurse is caring for a client who has pneumonia. Which of the following findings should the nurse report to the provider?
- A. Productive cough with green sputum
- B. Temperature of 37.1°C (98.8°F)
- C. Crackles in the lung bases
- D. Oxygen saturation of 95%
Correct Answer: C
Rationale: In a client with pneumonia, crackles in the lung bases can indicate fluid accumulation, worsening of the condition, or development of complications such as pulmonary edema. This finding should be reported to the provider promptly for further evaluation and management. Choices A, B, and D are common in clients with pneumonia and may not necessarily require immediate reporting unless accompanied by other concerning symptoms or vital sign abnormalities.
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A nurse is assessing a client who has chronic heart failure. Which of the following findings indicates that the client is experiencing fluid overload?
- A. Increased urine output
- B. Bounding peripheral pulses
- C. Weight loss
- D. Decreased heart rate
Correct Answer: B
Rationale: In clients with chronic heart failure, bounding peripheral pulses are a classic sign of fluid overload. This occurs due to increased volume in the arterial system, causing a forceful pulse. Increased urine output (Choice A) is often seen in clients with fluid volume deficit, not overload. Weight loss (Choice C) is also inconsistent with fluid overload as it suggests a fluid deficit. Decreased heart rate (Choice D) is more commonly associated with conditions like bradycardia, hypothyroidism, or the use of certain medications, but not specifically indicative of fluid overload in chronic heart failure.
A nurse is providing discharge instructions to a client who has a new prescription for warfarin. Which of the following statements indicates a need for further teaching?
- A. I will avoid leafy green vegetables while taking warfarin.
- B. I will have my INR checked regularly while taking warfarin.
- C. I will use a soft toothbrush while taking warfarin.
- D. I will take this medication at the same time each day.
Correct Answer: A
Rationale: The correct answer is A. Clients taking warfarin should avoid leafy green vegetables because they are high in vitamin K, which can interfere with the effectiveness of warfarin by counteracting its anticoagulant effects. Choices B, C, and D are all correct statements related to taking warfarin. Regular INR monitoring is necessary to ensure the medication is within the therapeutic range, using a soft toothbrush reduces the risk of bleeding gums, and taking the medication at the same time daily helps maintain consistent blood levels.
A nurse is reviewing the medical record of a client who has a history of angina and is scheduled for surgery. Which of the following findings should the nurse report to the provider?
- A. Serum potassium level of 4.2 mEq/L
- B. Blood pressure of 138/84 mm Hg
- C. Platelet count of 150,000/mm³
- D. INR of 2.0
Correct Answer: D
Rationale: The correct answer is D. An INR of 2.0 is within the therapeutic range for clients receiving warfarin. It is crucial to report this finding to the provider before surgery to ensure appropriate management and potential adjustments to prevent excessive bleeding risks. Choices A, B, and C are within normal limits and do not directly impact the client's surgery preparation or risk for bleeding, so they do not require immediate reporting.
What is the most important nursing assessment post-surgery?
- A. Monitor vital signs
- B. Monitor blood pressure
- C. Monitor the surgical site
- D. Monitor the incision site
Correct Answer: A
Rationale: The correct answer is to monitor vital signs post-surgery. Vital signs encompass various parameters like blood pressure, heart rate, respiratory rate, and temperature. Monitoring vital signs helps in early detection of complications such as hemorrhage, infection, or shock. While monitoring the surgical site and incision site are also essential post-surgery, monitoring vital signs takes precedence as it provides a broader assessment of the patient's overall condition. Monitoring blood pressure is part of vital sign assessment and is not the most comprehensive assessment post-surgery.
A nurse is providing discharge teaching to a client who is postoperative following a total hip arthroplasty. Which of the following instructions should the nurse include?
- A. Cross your legs when sitting to increase circulation.
- B. Bend at the waist when picking up objects.
- C. Avoid crossing your legs when sitting.
- D. Avoid using a raised toilet seat.
Correct Answer: C
Rationale: The correct answer is C: 'Avoid crossing your legs when sitting.' After a total hip arthroplasty, it is important for clients to avoid crossing their legs to prevent complications such as dislocation. Crossing the legs can put strain on the new hip joint, increasing the risk of dislocation. Choice A is incorrect as crossing legs can be harmful. Choice B is incorrect as bending at the waist can strain the hip joint, leading to complications. Choice D is incorrect as using a raised toilet seat is recommended after hip surgery to prevent excessive bending at the hip joint.