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A nurse is collecting data from a client who has heart failure. Which of the following findings should the nurse report to the provider?
- A. Activity tolerance
- B. Weight
- C. Chest x-ray results
- D. Echocardiogram results
Correct Answer: B
Rationale: Heart failure management hinges on detecting decompensation, where weight gain from fluid retention is a red flag. Sudden increases (e.g., 2-3 lbs overnight) signal worsening congestion, necessitating prompt provider action like diuretic adjustment. Activity tolerance reflects functional status but is subjective and less urgent unless acutely dropping. Chest x-ray results show pulmonary edema or cardiomegaly, but weight offers earlier, actionable data. Echocardiogram results assess heart function long-term, not immediate changes. Daily weight monitoring is a cornerstone of heart failure care fluid overload precedes symptoms like dyspnea, making it the priority to report. This aligns with clinical guidelines (e.g., ACC/AHA), enabling timely intervention to prevent hospitalization or acute failure, emphasizing its critical role in ongoing assessment.
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A nurse is collecting data from a female client who is postmenopausal. Which of the following findings should the nurse identify as a risk factor for the development of osteoporosis?
- A. Congenital heart murmur
- B. Long-term use of prednisone
- C. Monthly vitamin Bâ‚â‚‚ injections
- D. History of kidney stones
Correct Answer: B
Rationale: Osteoporosis risk rises postmenopause due to estrogen loss, but long-term prednisone use accelerates bone loss by inhibiting osteoblast activity and calcium absorption, a well-established glucocorticoid effect. Congenital heart murmur affects circulation, not bone density, unless activity is severely limited, which isn't implied. Vitamin Bâ‚â‚‚ injections treat deficiency, indirectly supporting bone health via red cell production, not increasing risk. Kidney stones relate to calcium metabolism but don't directly cause osteoporosis unless chronic disease alters bone remodeling, an uncommon link here. Prednisone's impact is direct, dose-dependent, and significant often warranting bisphosphonates making it the standout risk factor to identify, per osteoporosis screening guidelines (e.g., NOF), for preventive planning.
A nurse administered a dose of penicillin to a client 30 min ago. The client reports she has hives and is itching. Which of the following statements by the nurse is the highest priority?
- A. I'm going to take your heart rate.
- B. I need to give you diphenhydramine.
- C. Are you having difficulty breathing?
- D. Do you have any allergies to medications?
Correct Answer: C
Rationale: Asking about difficulty breathing is the priority as it assesses for anaphylaxis, a life-threatening allergic reaction to penicillin, requiring immediate intervention.
Exhibit 1 Exhibit 2 Exhibit 3
Graphic Record
Heart rate 112/min
Blood pressure 122/60 mm Hg
Temperature 38.6° C (101.5° F)
Respiratory rate 24/min
A nurse is reviewing the medical record of a client who has pneumonia. Which of the following information is the priority for the nurse to report to the provider?
- A. Sputum results
- B. Creatinine level
- C. Temperature
- D. WBC count
Correct Answer: C
Rationale: Pneumonia, an acute respiratory infection, requires monitoring for signs of worsening condition or treatment response. The exhibit shows heart rate 112/min, blood pressure 122/60 mm Hg, temperature 38.6°C (101.5°F), and respiratory rate 24/min. Option C, temperature, is the priority 38.6°C indicates fever, a key sign of active infection or potential sepsis, especially with tachycardia (112/min) and tachypnea (24/min). This triad suggests systemic inflammatory response, needing urgent provider attention to adjust antibiotics or assess deterioration. Option A, sputum results, guides therapy but isn't immediately actionable without context. Option B, creatinine, monitors kidney function but isn't the acute priority here. Option D, WBC count, reflects infection severity but fever drives immediate concern. Elevated temperature, per triage protocols, signals potential escalation, making it the most critical to report for timely intervention.
A nurse is providing first aid for a client who has a minor burn on one hand, which of the following actions should the nurse take? (Select all that apply.)
- A. Maintain skin integrity over the blisters.
- B. Apply ice to the larger blisters.
- C. Administer ibuprofen for pain.
- D. Run cool water over the affected area.
- E. Allow the affected area to remain open to air.
Correct Answer: A,C,D
Rationale: Maintaining blister integrity prevents infection (A), ibuprofen relieves pain (C), and cool water reduces heat and pain (D). Ice can damage tissue, and open air may increase infection risk.
A nurse in a health clinic is collecting data from an older adult client. Which of the following information in the client's history increases her risk for osteoporosis?
- A. The client is a gardener.
- B. The client is lactose intolerant.
- C. The client has a glass of red wine every evening
- D. The client walks 3.2 km (2 mi) daily.
- E. The client smokes daily.
- F. The client has a family history of osteoporosis.
- G. The client takes corticosteroids long-term.
Correct Answer: B
Rationale: Lactose intolerance limits calcium intake, a key risk factor for osteoporosis; gardening and walking are protective, and moderate wine has minimal impact.