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A nurse is reviewing the health histories of a group of clients. Which of the following findings should the nurse identify as an indication that a client is at an increased risk for urinary tract infections (UTIs)?
- A. Hypertension
- B. Diabetes mellitus
- C. Asthma
- D. Hyperthyroidism
Correct Answer: B
Rationale: The correct answer is B: Diabetes mellitus. Diabetes can lead to increased risk for UTIs due to elevated blood sugar levels creating a favorable environment for bacteria to grow in the urinary tract. High blood sugar weakens the immune system, making it harder to fight infections. Hypertension (A) is a condition related to high blood pressure, not directly associated with UTIs. Asthma (C) and hyperthyroidism (D) are not directly linked to an increased risk for UTIs.
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A nurse is caring for a client immediately following intubation with an endotracheal (ET) tube. Which of the following methods should the nurse identify as the most reliable for verifying placement of the ET tube?
- A. Observing for symmetrical chest rise and fall
- B. Auscultating bilateral breath sounds
- C. Using an end-tidal COâ‚‚ detector
- D. Checking for condensation in the ET tube
Correct Answer: C
Rationale: The correct answer is C: Using an end-tidal CO2 detector. This method is the most reliable for verifying ET tube placement because it directly measures the presence of CO2 in exhaled breath, confirming that the tube is in the trachea. This is crucial to prevent inadvertent esophageal intubation. Observing for symmetrical chest rise and fall (A) can be misleading as it can occur even with esophageal intubation. Auscultating bilateral breath sounds (B) can also be unreliable as breath sounds may be heard even if the tube is in the esophagus. Checking for condensation in the ET tube (D) is not a reliable method for verifying placement as condensation can occur regardless of tube placement.
A nurse notes that a clients eyes are protruding slightly from their orbits. Which of the following laboratory findings should the nurse expect?
- A. Decreased TSH levels
- B. Increased T4 levels
- C. Elevated calcium levels
- D. Low hemoglobin levels
Correct Answer: B
Rationale: The nurse should expect increased T4 levels in a client with slightly protruding eyes, known as exophthalmos, as it is a classic sign of hyperthyroidism, where the thyroid gland is overactive. Thyroid hormones, such as T4, are responsible for regulating metabolism, and elevated levels can lead to symptoms like exophthalmos. Decreased TSH levels (choice A) would actually be seen in primary hyperthyroidism due to negative feedback. Elevated calcium levels (choice C) are more indicative of hyperparathyroidism. Low hemoglobin levels (choice D) are not typically associated with exophthalmos or hyperthyroidism.
A nurse is assessing a group of clients. For which of the following clients should the nurse make a referral to palliative care?
- A. A client receiving chemotherapy for early-stage breast cancer.
- B. A client whose medications to manage Parkinsons disease are no longer effective.
- C. A client recovering from a total knee replacement.
- D. A client with seasonal allergies needing symptom relief.
Correct Answer: B
Rationale: The correct answer is B because the client with Parkinson's disease whose medications are no longer effective may benefit from the specialized care and symptom management provided by palliative care. Palliative care focuses on improving quality of life for individuals with serious illnesses by addressing physical, emotional, and spiritual needs. Referral is appropriate when symptoms are not adequately controlled. Choices A, C, and D do not require palliative care as they involve routine treatments or procedures that do not necessarily indicate the need for specialized palliative services.
A nurse is assessing a clients ECG strip and notes an irregular heart rate of 98/min with no clear P waves. Which of the following cardiac dysrhythmias should the nurse document?
- A. Sinus bradycardia
- B. Atrial fibrillation
- C. Ventricular tachycardia
- D. First-degree heart block
Correct Answer: B
Rationale: The correct answer is B: Atrial fibrillation. In atrial fibrillation, the heart rate is irregular and fast (98/min), and there are no clear P waves on the ECG strip, which aligns with the findings in the scenario. Atrial fibrillation is characterized by chaotic electrical activity in the atria, leading to an irregular heart rate. Sinus bradycardia (A) is characterized by a slow heart rate with normal P waves. Ventricular tachycardia (C) is a fast heart rhythm originating in the ventricles with distinct QRS complexes. First-degree heart block (D) is identified by a prolonged PR interval but should still have clear P waves. Other choices are not relevant. In this case, the absence of clear P waves and irregular heart rate point towards atrial fibrillation as the correct dysrhythmia to document.
A nurse is caring for a group of clients. In which of the following scenarios is the nurse acting as a client advocate?
- A. Encouraging a client to take pain medication despite refusal.
- B. Referring a client who has COPD for palliative care services.
- C. Discharging a client early to free up hospital beds.
- D. Withholding information about a new diagnosis to prevent distress.
Correct Answer: B
Rationale: The correct answer is B because referring a client with COPD for palliative care services demonstrates advocating for the client's best interest, ensuring they receive appropriate care to manage symptoms and improve quality of life. This action aligns with the nurse's role as a client advocate by advocating for the client's autonomy and well-being. In contrast, choices A, C, and D do not prioritize the client's best interests or rights. Choice A disregards the client's autonomy by encouraging medication against their wishes. Choice C prioritizes hospital efficiency over the client's needs. Choice D violates the client's right to informed decision-making by withholding essential information. Overall, choice B best exemplifies client advocacy in nursing practice.