Nokea
A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?
- A. Blood pressure
- B. Heart rate
- C. Urine output
- D. Respiratory rate
Correct Answer: B
Rationale: The correct answer is B: Heart rate. A decrease in heart rate indicates adequate fluid replacement in a burn-injured patient due to improved cardiac output and perfusion. When fluid resuscitation is effective, the heart doesn't need to work as hard to maintain circulation. Blood pressure (choice A) may fluctuate initially but is not a reliable indicator of fluid replacement alone. Urine output (choice C) is important but may take time to stabilize. Respiratory rate (choice D) may be affected by pain or stress, not solely fluid status. Other choices are not relevant.
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A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. Which of the following laboratory tests are used to diagnose a myocardial infarction? (Select all that apply.)
- A. Troponin I, Troponin T, CPK, Myoglobin
- B. Plasma low-density lipoproteins
- C. White blood cell count
- D. Blood glucose level
Correct Answer: A
Rationale: The correct answer is A. Troponin I, Troponin T, CPK, and Myoglobin are all specific laboratory tests used to diagnose a myocardial infarction. Troponin I and T are cardiac biomarkers released into the bloodstream following myocardial cell injury. Creatine phosphokinase (CPK) is an enzyme found in high concentrations in the heart muscle, and elevated levels indicate myocardial damage. Myoglobin is a protein released from damaged muscle cells, including cardiac muscle. These tests provide crucial information to confirm the diagnosis of a myocardial infarction.
Plasma low-density lipoproteins are not specific for diagnosing a myocardial infarction. White blood cell count is not typically used for diagnosing a myocardial infarction, although it may be elevated in response to inflammation associated with heart damage. Blood glucose level is not specific for diagnosing a myocardial infarction and
A nurse is caring for a client who has myelosuppression after receiving chemotherapy. The nurse should monitor the client for which of the following adverse effects?
- A. Bleeding from the gums
- B. Chest pain
- C. Fatigue
- D. Severe headache
Correct Answer: A
Rationale: The correct answer is A: Bleeding from the gums. Myelosuppression leads to decreased production of blood cells, including platelets, which are essential for clotting. Bleeding from the gums is a common sign of thrombocytopenia, a condition where there are low platelet levels. Chest pain, fatigue, and severe headache are not directly associated with myelosuppression. Monitoring for bleeding tendencies is crucial in clients with myelosuppression to prevent complications like hemorrhage.
A nurse is caring for a client with a sucking chest wound from a gunshot. What action should the nurse take?
- A. Administer oxygen via nasal cannula.
- B. Place the client in Trendelenburg position.
- C. Apply a warm compress to the wound.
- D. Encourage deep breathing exercises.
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen via nasal cannula. This is the priority action to ensure the client receives adequate oxygenation. In a sucking chest wound, air enters the pleural space, leading to a potential pneumothorax, which can compromise oxygenation. Administering oxygen helps maintain oxygen saturation levels and supports respiratory function. Placing the client in Trendelenburg position (choice B) can worsen respiratory distress by increasing pressure on the diaphragm. Applying a warm compress (choice C) may promote bleeding and is not effective in managing a sucking chest wound. Encouraging deep breathing exercises (choice D) can further exacerbate the pneumothorax by allowing more air to enter the pleural space.
A nurse in a clinic is teaching information about cervical polyps with a client who has a new diagnosis. Which of the following information should the nurse include in the teaching?
- A. Postcoital bleeding may occur.
- B. A pelvic ultrasound is required for diagnosis.
- C. Cervical polyps usually resolve without treatment.
- D. Cervical polyps are rarely associated with cancer.
Correct Answer: A
Rationale: The correct answer is A: Postcoital bleeding may occur. This information is essential to include in teaching about cervical polyps because it is a common symptom associated with this condition. Cervical polyps are benign growths on the cervix that can cause bleeding, especially after intercourse. It is crucial for the client to be aware of this symptom to monitor for any abnormal bleeding and seek medical attention if necessary.
Option B is incorrect because a pelvic ultrasound is not always required for diagnosing cervical polyps; they can often be diagnosed through a pelvic exam. Option C is incorrect because not all cervical polyps resolve on their own and may require treatment if symptomatic. Option D is incorrect because while cervical polyps are usually benign, they can be associated with an increased risk of cervical cancer in some cases.
A nurse is caring for a client who has heart failure and a new prescription for furosemide. For which of the following adverse effects should the nurse monitor?
- A. Hypokalemia
- B. Hyperkalemia
- C. Hypernatremia
- D. Hypertension
Correct Answer: A
Rationale: The correct answer is A: Hypokalemia. Furosemide is a loop diuretic that can cause potassium loss through increased urine output. This can lead to hypokalemia, which can be dangerous in a client with heart failure as it can worsen cardiac function and lead to arrhythmias. The nurse should monitor the client's potassium levels regularly to prevent this adverse effect.
Summary of other choices:
B: Hyperkalemia - Furosemide does not typically cause hyperkalemia.
C: Hypernatremia - Furosemide is a diuretic that can lead to sodium loss, not hypernatremia.
D: Hypertension - Furosemide is actually used to treat hypertension, so it is not an adverse effect of the medication in this scenario.