Nokea
A nurse is collecting data from a client who had a bronchoscopy. Which of the following findings should the nurse report to the provider?
- A. Sore throat
- B. Blood pressure 110/78 mm Hg
- C. Presence of gag reflex
- D. Facial edema
Correct Answer: D
Rationale: Post-bronchoscopy, nurses monitor for complications like bleeding, infection, or airway issues. Option A, sore throat, is a common, benign side effect from the scope, not requiring immediate reporting. Option B, blood pressure 110/78 mm Hg, is normal and stable, needing no action. Option C, presence of gag reflex, is reassuring it indicates airway protection is intact post-sedation, a positive sign. Option D, facial edema, is correct to report it's abnormal and could signal an allergic reaction to sedation, airway swelling, or trauma from the procedure, potentially compromising breathing. This finding demands urgent provider evaluation to rule out anaphylaxis or obstruction, aligning with airway management priorities. While sore throat and gag reflex are expected, facial edema deviates from the norm, requiring swift intervention to prevent escalation, making it the critical finding to escalate.
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Medical History
Today, 0700:
Admitting Diagnosis: Heart Failure
Past medical history of heart failure, coronary artery disease, sleep apnea
Client reports diarrhea, dry mouth, and unusual thirst for the past three days
A nurse is assisting in the care of a male client who has a new prescription for furosemide. Which of the following client findings should the nurse identify as a contraindication to the administration of furosemide?
- A. Potassium level
- B. Blood pressure
- C. Prescription for digoxin
- D. Client verbal report
- E. BUN
Correct Answer: A
Rationale: Furosemide, a loop diuretic, treats heart failure but depletes potassium, risking hypokalemia. A low potassium level (e.g., <3.5 mEq/L) contraindicates its use hypokalemia causes arrhythmias, especially with heart failure's cardiac strain, per pharmacology standards. Blood pressure matters hypotension may worsen with diuresis but isn't a direct contraindication unless extreme. Digoxin use heightens hypokalemia risk (enhancing toxicity), but potassium level drives the decision. The client's report of diarrhea and thirst suggests dehydration, a caution, not a strict contraindication. Low potassium demands correction (e.g., supplements) before furosemide, preventing lethal complications like ventricular fibrillation, making it the critical finding to identify.
History and Physical
1000:
Client reports generalized weakness and increased fatigue over the past few months.
Client states they become short of breath after climbing a flight of stairs and are having difficulty keeping up with their grandchildren.
History of rheumatoid arthritis. Reports taking naproxen 500 mg twice a day.
Client reports they follow a vegan diet.
Denies pain or discomfort.
Bilateral breath sounds clear and present throughout.
Mucous membranes pale.
Apical pulse rapid, regular.
Diagnostic Results
1000:
Hct 24% (37% to 47%)
Hgb 8 g/dL (12 to 16 g/dL)
RBC count 3 x 10 ⁶ pL (4.2 to 5.4 x 10 ⁶ pL)
Ferritin 8 ng/mL (10 to 150 ng/mL)
WBC count 9,000/mm ³ (5,000 to 10,000/mm ³)
Platelet count 180,000/mm ³ (150,000 to 400,000/mm ³)
Vitamin B ₁₂ 159 pg/mL (160 to 950 pg/mL)
Complete the following sentence by using the lists of options.The first action the nurse should take is to followed by (Client with low Hct, Hgb, vegan diet)
- A. reinforce education about nutritional supplements
- B. collecting data about nutritional intake
- C. administer IV fluids
- D. notify the provider
- E. monitor vital signs
- F. prepare for transfusion
- G. document findings
Correct Answer: B,A
Rationale: Collecting nutritional data identifies deficiencies (e.g., B12, iron from vegan diet), followed by education on supplements.
A nurse is reinforcing dietary teaching with an older adult client who has an increased LDL level. Which of the following foods should the nurse encourage the client to limit?
- A. Canola oil
- B. Swiss cheese
- C. Avocados
- D. Walnuts
- E. Olive oil
- F. Fatty fish
- G. Whole grains
Correct Answer: B
Rationale: Swiss cheese is high in saturated fat, raising LDL; canola oil, avocados, and walnuts are heart-healthy.
47
A nurse is caring for a client who has deep-vein thrombosis. Which of the following interventions should the nurse plan to take?
- A. Place the client's bed in reverse Trendelenburg position.
- B. Massage the affected extremity every 4 hr.
- C. Apply cold compresses to the affected extremity.
- D. Measure the calf of the affected extremity each shift.
- E. Elevate the leg.
- F. Apply warm compresses.
- G. Administer heparin.
Correct Answer: D
Rationale: Measuring the calf monitors for swelling (worsening DVT); massage and cold can dislodge clots, and reverse Trendelenburg isn't specific.
A nurse is reinforcing teaching with a client who has heart failure and a new prescription for furosemide. The nurse should instruct the client to monitor for which of the following adverse effects?
- A. Rhinitis
- B. Metallic taste
- C. Ringing in ears
- D. Agitation
- E. Weight gain
- F. Dry cough
- G. Blurred vision
Correct Answer: C
Rationale: Ringing in ears (tinnitus) is a sign of furosemide ototoxicity; rhinitis and metallic taste aren't typical.