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A nurse is caring for a client who is experiencing an exacerbation of heart failure. Which of the following findings indicate potential improvement?
- A. Hgb 8.4 g/dL (12 to 18 g/dL)
- B. Hct 42% (37% to 47%)
- C. WBC count 9
- D. Potassium 4.3 mEq/L (3.5 to 5 mEq/L)
Correct Answer: D
Rationale: The correct answer is D: Potassium 4.3 mEq/L (3.5 to 5 mEq/L). In heart failure exacerbation, potassium levels can be affected due to medications or fluid shifts. A potassium level within the normal range indicates electrolyte balance, which is crucial for cardiac function. Hemoglobin (Choice A) and hematocrit (Choice B) are indicators of oxygen-carrying capacity and volume status, not directly related to heart failure improvement. White blood cell count (Choice C) is not specific to heart failure exacerbation. Therefore, the correct answer is D as it reflects a positive change in electrolyte balance, essential for cardiac function.
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A nurse is caring for a client who is receiving morphine through a PCA device. Which of the following actions should the nurse take?
- A. Teach the client how to self-medicate using the PCA device.
- B. Encourage family members to press the PCA button for the client.
- C. Monitor the client's respiratory status every 4 hr.
- D. Administer an oral opioid for breakthrough pain.
Correct Answer: A
Rationale: The correct answer is A: Teach the client how to self-medicate using the PCA device. This is important because it empowers the client to control their pain management while ensuring safety. Teaching the client how to use the PCA device helps promote autonomy and ensures that the client is receiving the appropriate dose of medication as prescribed. Encouraging family members to press the button (B) may lead to inappropriate dosing and compromise the client's safety. Monitoring respiratory status (C) is important but should be done more frequently, such as every hour, as respiratory depression can occur with morphine use. Administering an oral opioid for breakthrough pain (D) may not be necessary if the client is able to self-medicate effectively with the PCA device.
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. Butterfly' rash
- C. Esophagitis
- D. Trophil
Correct Answer: A
Rationale: The correct answer is A: Joint inflammation. Systemic lupus erythematosus (SLE) commonly presents with joint inflammation due to inflammation of the synovial membrane. This can lead to pain, swelling, and stiffness in the joints. The other choices are incorrect because: B: Butterfly rash is a characteristic facial rash seen in SLE, but it is not related to joint involvement. C: Esophagitis is inflammation of the esophagus and is not a common manifestation of SLE. D: Trophil is not a recognized term in relation to SLE or its symptoms.
A nurse is assessing the pain status of a group of clients. Which of the following findings indicates a client is experiencing referred pain?
- A. A client who has peritonitis reports generalized abdominal pain.
- B. A client who has angina reports substernal chest pain.
- C. A client who is postoperative reports incisional pain.
- D. A client who has pancreatitis reports pain in the left shoulder.
Correct Answer: D
Rationale: Referred pain is pain perceived at a site different from its point of origin. In the case of pancreatitis, pain is often referred to the left shoulder due to shared nerve pathways. The other choices involve pain directly related to the affected area (peritonitis, angina, postoperative incision), making them incorrect.
A nurse is caring for a client who has acute angina. Which of the following actions should the nurse take first?
- A. Measure blood pressure.
- B. Administer aspirin.
- C. Administer nitroglycerin.
- D. Initiate IV access.
Correct Answer: B
Rationale: The correct answer is B: Administer aspirin. Aspirin helps to reduce platelet aggregation and prevent further clot formation in clients with acute angina, thus reducing the risk of myocardial infarction. Administering aspirin should be the first action as it addresses the immediate risk of clot formation and helps improve blood flow to the heart muscle.
Measuring blood pressure (A) can be important but is not the priority in this situation. Administering nitroglycerin (C) is important for symptom relief but does not address the underlying cause. Initiating IV access (D) may be necessary later for further interventions, but it is not the first priority.
A nurse is caring for a client who has a history of chemotherapy-induced nausea and vomiting. Which of the following medications should the nurse administer prior to chemotherapy?
- A. Selenaline
- B. Ondansetron
- C. Diphenhydramine
- D. Methylprednisolone
Correct Answer: B
Rationale: The correct answer is B: Ondansetron. Ondansetron is a commonly used antiemetic medication that helps prevent chemotherapy-induced nausea and vomiting by blocking serotonin receptors in the gastrointestinal tract and chemoreceptor trigger zone. Administering ondansetron before chemotherapy can effectively reduce the incidence of these side effects. Selenaline (A) is not a recognized medication for managing chemotherapy-induced nausea and vomiting. Diphenhydramine (C) is an antihistamine that may be used for other types of nausea but is not the first-line treatment for chemotherapy-induced nausea. Methylprednisolone (D) is a corticosteroid that may be used to reduce inflammation but is not typically used as a primary antiemetic for chemotherapy-induced nausea and vomiting.