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A nurse is reviewing the laboratory results of a client who has heart failure. Which of the following findings should the nurse report to the provider?
- A. Potassium 4.0 mEq/L
- B. Hemoglobin 12 g/dL
- C. BUN 18 mg/dL
- D. Sodium 137 mEq/L
Correct Answer: B
Rationale: The correct answer is B: Hemoglobin 12 g/dL. In a client with heart failure, a decrease in hemoglobin levels can indicate anemia, which can exacerbate heart failure symptoms. Reporting this finding to the provider is crucial for appropriate management. Choice A, Potassium 4.0 mEq/L, is within the normal range (3.5-5.0 mEq/L) and does not typically require immediate reporting. Choice C, BUN 18 mg/dL, and Choice D, Sodium 137 mEq/L, are also within normal ranges and not directly related to heart failure management. Therefore, the hemoglobin level is the most critical finding to report in this scenario.
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A nurse is observing bonding between a client and her newborn. Which of the following actions by the client requires the nurse to intervene?
- A. Holding the newborn in an en face position
- B. Asking the father to change the newborn's diaper
- C. Requesting the nurse to take the newborn to the nursery so she can rest
- D. Viewing the newborn's actions as uncooperative
Correct Answer: D
Rationale: The correct answer is D because viewing the newborn's actions as uncooperative indicates a lack of bonding, which requires intervention. Choices A, B, and C all involve appropriate and caring actions by the client towards the newborn. Holding the newborn in an en face position promotes bonding, involving the father in caring for the newborn is beneficial for family involvement, and requesting rest by asking the nurse to take the newborn to the nursery is a responsible action to ensure both the client and the newborn get adequate rest.
What is the priority intervention for a patient with suspected pulmonary embolism?
- A. Administer oxygen
- B. Administer anticoagulants
- C. Administer bronchodilators
- D. Reposition the patient
Correct Answer: A
Rationale: Administering oxygen is the priority intervention for a patient with suspected pulmonary embolism. Maintaining adequate oxygenation is crucial in these patients to prevent hypoxemia and support oxygen delivery to tissues. Administering anticoagulants may be necessary but is not the initial priority. Administering bronchodilators is not indicated for pulmonary embolism. Repositioning the patient does not address the immediate need for oxygenation.
What is the appropriate action for a patient experiencing chest pain?
- A. Administer aspirin
- B. Reposition the patient
- C. Check oxygen saturation
- D. Prepare for surgery
Correct Answer: A
Rationale: The correct action for a patient experiencing chest pain is to administer aspirin. Aspirin helps reduce the risk of clot formation in patients with chest pain, as it has antiplatelet effects. Repositioning the patient may not address the underlying cause of the chest pain. Checking oxygen saturation is important but not the initial priority in this scenario. Surgery is not typically the first-line treatment for chest pain without further assessment and diagnostic procedures.
A nurse is caring for a client who is receiving continuous enteral feeding through a nasogastric tube. Which of the following actions should the nurse take to prevent aspiration?
- A. Flush the tube with 30 mL of water every 4 hours.
- B. Position the client on the left side during feedings.
- C. Elevate the head of the bed to 45 degrees during feedings.
- D. Check gastric residual every 2 hours.
Correct Answer: C
Rationale: To prevent aspiration in clients receiving continuous enteral feedings, the nurse should elevate the head of the bed to 45 degrees. This position helps reduce the risk of regurgitation and aspiration. Flushing the tube with water every 4 hours (Choice A) is important for maintaining tube patency but does not directly prevent aspiration. Positioning the client on the left side during feedings (Choice B) is not specifically related to preventing aspiration in this context. Checking gastric residual every 2 hours (Choice D) is important to assess feeding tolerance but does not directly prevent aspiration.
What is the priority nursing intervention for a patient with hyperkalemia?
- A. Administer calcium gluconate
- B. Administer insulin
- C. Administer sodium bicarbonate
- D. Administer a diuretic
Correct Answer: A
Rationale: The correct answer is to administer calcium gluconate. In hyperkalemia, the priority is to protect the heart from potential complications like arrhythmias. Calcium gluconate is the first-line treatment as it stabilizes the cardiac cell membrane. Insulin (Choice B) and sodium bicarbonate (Choice C) can be used in conjunction with other treatments to shift potassium into cells, but calcium gluconate is the priority. Administering a diuretic (Choice D) is not the primary intervention for hyperkalemia and can even worsen the condition by reducing potassium excretion.