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A nurse is planning care for a client who has pneumonia. Which of the following actions should the nurse take to promote airway clearance?
- A. Perform chest physiotherapy every 4 hours.
- B. Suction the client every 2 hours.
- C. Encourage the client to increase fluid intake.
- D. Administer oxygen via nasal cannula.
Correct Answer: C
Rationale: Encouraging the client to increase fluid intake is essential in promoting airway clearance for a client with pneumonia. Increased fluid intake helps thin secretions, making it easier for the client to clear their airways. Chest physiotherapy (Choice A) is more focused on mobilizing secretions and may not be suitable for all clients with pneumonia. Suctioning (Choice B) is indicated for clients who have excessive secretions that they cannot manage effectively themselves. Administering oxygen via nasal cannula (Choice D) is important for clients with pneumonia to maintain adequate oxygenation, but it does not directly promote airway clearance.
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Which of the following lab values should the nurse monitor for a patient receiving heparin therapy?
- A. Monitor platelet count
- B. Monitor PT/INR
- C. Monitor aPTT
- D. Monitor CBC
Correct Answer: C
Rationale: The correct answer is to monitor aPTT for a patient receiving heparin therapy. The activated partial thromboplastin time (aPTT) is used to assess and adjust heparin dosage to ensure the patient is within the therapeutic range for anticoagulation. Monitoring the aPTT helps in preventing both clotting and bleeding complications. Platelet count (Choice A) is important to monitor for patients receiving antiplatelet therapy, not heparin. PT/INR (Choice B) is typically monitored for patients on warfarin therapy, not heparin. Monitoring the complete blood count (CBC) (Choice D) is essential for various conditions but is not specific to monitoring heparin therapy.
How should a healthcare professional assess for fluid overload in a patient with heart failure?
- A. Monitor daily weight
- B. Check for edema
- C. Monitor blood pressure
- D. Check oxygen saturation
Correct Answer: A
Rationale: Monitoring daily weight is the most accurate way to assess fluid overload in patients with heart failure. In heart failure, the body retains excess fluid, leading to weight gain. Monitoring daily weight allows healthcare professionals to track fluid retention accurately. Checking for edema (Choice B) is a valuable assessment technique, but it may not be as sensitive as monitoring daily weight. Monitoring blood pressure (Choice C) is essential in managing heart failure, but it is not the most accurate way to assess fluid overload. Checking oxygen saturation (Choice D) is important to assess respiratory status but is not directly related to fluid overload in heart failure.
A client with diabetes mellitus is being taught by a nurse on managing hypoglycemia. Which of the following instructions should the nurse include?
- A. Avoid consuming carbohydrate-rich foods.
- B. Consume 15 grams of a fast-acting carbohydrate.
- C. Drink a glass of water to raise blood glucose levels.
- D. Eat a snack before exercising to prevent hypoglycemia.
Correct Answer: B
Rationale: The correct answer is B: Consume 15 grams of a fast-acting carbohydrate. Consuming 15 grams of a fast-acting carbohydrate, such as glucose tablets or juice, helps raise blood glucose levels quickly in cases of hypoglycemia. Choice A is incorrect because avoiding carbohydrate-rich foods during hypoglycemia can worsen the condition. Choice C is incorrect as drinking water does not effectively raise blood glucose levels. Choice D is incorrect as eating a snack before exercising is more related to preventing exercise-induced hypoglycemia, not managing hypoglycemia.
A client has had a nasogastric tube in place for 2 days. Which of the following findings indicates that the client has developed an adverse effect?
- A. Dry mucous membranes
- B. Polyuria
- C. Epistaxis
- D. Diarrhea
Correct Answer: C
Rationale: The correct answer is C, 'Epistaxis.' Epistaxis (nosebleed) is a common adverse effect of prolonged nasogastric tube insertion due to irritation of the nasal mucosa. Dry mucous membranes (choice A) may indicate dehydration but are not a direct adverse effect of nasogastric tube insertion. Polyuria (choice B) is excessive urination and is not typically associated with nasogastric tube insertion. Diarrhea (choice D) is also not a common adverse effect of having a nasogastric tube in place.
A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider?
- A. Increased hoarseness
- B. Serum calcium level of 8.0 mg/dL
- C. Respiratory rate of 18/min
- D. Urinary output of 60 mL in 2 hours
Correct Answer: B
Rationale: The correct answer is B: 'Serum calcium level of 8.0 mg/dL.' A low serum calcium level indicates hypocalcemia, which is a potential complication of thyroidectomy that can lead to life-threatening consequences, such as tetany or laryngospasm. Therefore, it is crucial for the nurse to report this finding promptly to the provider for timely intervention. Choices A, C, and D are important assessments following a thyroidectomy but are not as critical as detecting and addressing hypocalcemia, which can have serious implications for the client's health.