Nokea
A nurse is caring for a client who is receiving IV fluids and develops dyspnea. Which of the following actions should the nurse take first?
- A. Elevate the head of the bed.
- B. Increase the infusion rate.
- C. Administer oxygen.
- D. Notify the provider.
Correct Answer: A
Rationale: Elevating the head of the bed is the first action to improve breathing in a client with dyspnea, facilitating lung expansion.
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A nurse is monitoring a client's lower extremity following the placement of a cast earlier in the day. Which of the following findings should the nurse identify as manifestations of compartment syndrome? (Select all that apply.)
- A. Pale-colored toes
- B. Decreased skin turgor
- C. Pain relieved by analgesia
- D. Diminished capillary refill
- E. Sensation of tingling
Correct Answer: A,D,E
Rationale: Pale-colored toes are a sign of compromised circulation, which is a key manifestation of compartment syndrome. Decreased blood flow to the affected limb can cause pallor, which requires immediate intervention to prevent permanent damage. Diminished capillary refill is correct. Delayed capillary refill (longer than 2 seconds) suggests poor perfusion, which can indicate increased pressure within the compartment. Sensation of tingling is correct. Paresthesia (tingling or numbness) is an early sign of nerve compression due to swelling within the compartment. If untreated, this can progress to permanent nerve and muscle damage.
A nurse is caring for a client who has a new prescription for lorazepam. Which of the following adverse effects should the nurse monitor for?
- A. Drowsiness
- B. Weight gain
- C. Hyperglycemia
- D. Tinnitus
Correct Answer: A
Rationale: Lorazepam, a benzodiazepine, commonly causes drowsiness, which can affect the client's safety and coordination.
A nurse is reinforcing teaching with a client who has a new prescription for methotrexate. Which of the following laboratory values should the nurse monitor?
- A. Liver function tests
- B. Hemoglobin A1c
- C. Serum creatinine
- D. Cholesterol
Correct Answer: A
Rationale: Methotrexate can cause hepatotoxicity, so monitoring liver function tests is essential to detect potential liver damage.
A nurse is reinforcing teaching with a client who has a new prescription for omeprazole. Which of the following adverse effects should the nurse include?
- A. Diarrhea
- B. Weight loss
- C. Tinnitus
- D. Hypotension
Correct Answer: A
Rationale: Omeprazole, a proton pump inhibitor, can cause diarrhea as a common side effect due to changes in gut flora.
A nurse is caring for a client who has an indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take?
- A. Instruct the client to hold the drainage bag at waist height when ambulating.
- B. Coil the tubing on the bed above the collection bag.
- C. Collect a sterile specimen from the urinary drainage bag.
- D. Secure the tubing with adhesive tape to the lower abdomen.
Correct Answer: D
Rationale: Securing the tubing with adhesive tape to the lower abdomen is correct. For male clients, securing the catheter to the lower abdomen prevents urethral trauma and tension. For female clients, the catheter is typically secured to the inner thigh to minimize movement and irritation.