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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 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.
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 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.
A nurse is assessing a preoperative client for allergies. Which of the following client statements would the nurse identify as a risk for an allergy to latex?
- A. I break out in a rash when I eat strawberries.'
- B. I often have diarrhea after eating scrambled eggs.'
- C. I have trouble breathing if I eat acidic foods.'
- D. I sometimes start to wheeze when I eat peanuts.'
Correct Answer: D
Rationale: The correct answer is D because wheezing after consuming peanuts indicates a potential allergic reaction, which could also extend to latex due to cross-reactivity. Peanuts and latex share similar proteins, leading to potential allergic responses. Choices A, B, and C do not indicate a direct correlation to latex allergy and are unrelated symptoms.
A nurse is caring for a client who has left-sided heart failure. Which of the following manifestations should the nurse expect?
- A. Crackles
- B. Decreased urine output
- C. Daytime oliguria
- D. Halo vision
Correct Answer: A
Rationale: The correct answer is A: Crackles. Left-sided heart failure causes fluid buildup in the lungs, leading to pulmonary congestion. Crackles are indicative of fluid in the alveoli, a common sign of pulmonary edema in heart failure. Decreased urine output (B), daytime oliguria (C), and halo vision (D) are not specific to left-sided heart failure. Decreased urine output and oliguria are more associated with kidney dysfunction, while halo vision is related to eye conditions like cataracts.