Nokea
A nurse is planning care for a client who has a new diagnosis of acute pancreatitis. Which of the following interventions should the nurse include in the plan of care?
- A. Administer antihypertensive medications.
- B. Maintain the client on NPO status.
- C. Place the client in a supine position.
- D. Monitor the client for hypercalcemia.
Correct Answer: B
Rationale: The correct answer is B: Maintain the client on NPO status. In acute pancreatitis, the pancreas is inflamed, leading to digestive enzyme release and potential autodigestion of pancreatic tissue. Keeping the client NPO (nothing by mouth) helps rest the pancreas by reducing stimulation of enzyme secretion. This allows the pancreas to heal and decreases the risk of further complications. Administering antihypertensive medications (A) is not typically a priority for acute pancreatitis. Placing the client in a supine position (C) may not directly impact the pancreatitis. Monitoring for hypercalcemia (D) is important in chronic pancreatitis but not typically a primary intervention in the acute phase.
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A nurse is assessing a client who is taking telmisartan. The nurse should identify that which of the following findings indicates that the medication has been effective?
- A. Blood glucose of 110 mg/dL
- B. Decrease in blood pressure
- C. Increase in urinary output
- D. Respiratory rate of 10/min
Correct Answer: B
Rationale: The correct answer is B: Decrease in blood pressure. Telmisartan is an angiotensin II receptor blocker used to treat hypertension by lowering blood pressure. Therefore, a decrease in blood pressure would indicate that the medication has been effective. Choice A, blood glucose of 110 mg/dL, is unrelated to the action of telmisartan. Choice C, increase in urinary output, is not a direct effect of telmisartan. Choice D, respiratory rate of 10/min, is not a typical indicator of the effectiveness of telmisartan in managing hypertension.
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 teaching a client who has a new prescription for warfarin about foods that affect the INR. The nurse should include in the teaching that which of the following foods interacts with this medication?
- A. Orange juice
- B. Cabbage
- C. Beef stew
- D. Vegetable oil
Correct Answer: B
Rationale: The correct answer is B: Cabbage. Cabbage is high in vitamin K, which can counteract the effects of warfarin, a medication that works by blocking the action of vitamin K in the blood. Consuming large amounts of foods high in vitamin K, like cabbage, can decrease the effectiveness of warfarin and increase the risk of blood clots. Orange juice (A), beef stew (C), and vegetable oil (D) do not significantly affect INR levels or interact with warfarin in the same way as vitamin K-rich foods like cabbage.
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.
A nurse is caring for a client who is postoperative following an endoscopy with moderate (conscious) sedation. Which of the following assessment findings is the nurse's priority?
- A. Oxygen saturation
- B. Warm extremities
- C. Temperature
- D. Level of pain
Correct Answer: A
Rationale: The correct answer is A: Oxygen saturation. Ensuring adequate oxygen saturation is the nurse's priority because the client received moderate sedation, which can depress the respiratory drive. Monitoring oxygen saturation helps to detect any signs of respiratory distress early on. Warm extremities (B) and temperature (C) are important but not the priority in this situation. Pain management (D) is important but not as critical as ensuring adequate oxygenation.