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A nurse is reviewing the medical record of a client who reports drinking three to four glasses of wine each night and taking 3,000 mg of acetaminophen daily. Which of the following laboratory values is the priority for the nurse to assess?
- A. Creatinine
- B. Aspartate aminotransferase (AST)
- C. Amylase
- D. Antidiuretic hormone (ADH)
Correct Answer: B
Rationale: The correct answer is B: Aspartate aminotransferase (AST). The nurse should prioritize assessing AST because both alcohol consumption and acetaminophen use can lead to liver damage. Elevated AST levels indicate liver injury, making it crucial to monitor for potential hepatotoxicity in this client. Creatinine (choice A) is typically assessed to evaluate kidney function, not directly related to alcohol or acetaminophen use. Amylase (choice C) is an enzyme related to pancreas health, not specifically affected by alcohol or acetaminophen. Antidiuretic hormone (ADH - choice D) is related to fluid balance, not a priority in this scenario. By focusing on AST, the nurse can promptly identify any liver damage and intervene accordingly.
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A nurse is preparing to administer ciprofloxacin to a client. The nurse should identify that the medication is treatment for exposure to which of the following agents?
- A. Smallpox
- B. Anthrax
- C. Ebola virus
- D. Sarin gas
Correct Answer: B
Rationale: The correct answer is B: Anthrax. Ciprofloxacin is an antibiotic commonly used to treat anthrax, which is a bacterial infection caused by Bacillus anthracis. The rationale behind this choice is that ciprofloxacin is effective in treating anthrax infections by inhibiting the growth of the bacteria. Smallpox (A), Ebola virus (C), and Sarin gas (D) are not treated with ciprofloxacin as they are caused by a virus, a different virus, and a nerve gas, respectively.
A nurse is preparing to perform an abdominal assessment on a client. Identify the sequence of steps the nurse should take to conduct the assessment. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
- A. Inspect the abdomen for skin integrity.
- B. Ask the client about having a history of abdominal pain.
- C. Auscultate the abdomen for bowel sounds.
- D. Percuss the abdomen in each of the four quadrants.
- E. Palpate the abdomen gently for tenderness.
Correct Answer: A,B,C,D,E
Rationale: Action to Take: A, B; Potential Condition: None; Parameter to Monitor: C, E.
Rationale:
1. Inspecting for skin integrity (A) allows the nurse to assess for any visible abnormalities or lesions.
2. Asking about abdominal pain history (B) provides insight into potential underlying conditions.
3. Auscultating for bowel sounds (C) helps assess gastrointestinal motility and function.
4. Percussing the abdomen (D) helps identify areas of abnormal fluid or gas accumulation.
5. Palpating for tenderness (E) assesses for pain or masses in the abdomen.
Summary:
- Not inspecting the abdomen (A) could miss skin abnormalities.
- Not asking about abdominal pain history (B) could overlook important medical information.
- Skipping auscultation (C) could lead to missing crucial gastrointestinal assessment.
- Not percussing (D) may result in overlooking potential abdominal issues.
- Omitting palpation (E) could miss detecting tend
A nurse is assessing a client who is receiving metoprolol. Which of the following indicates a therapeutic effect?
- A. Decreased blood pressure.
- B. Decreased dysrhythmias.
- C. Increased urine output.
- D. Decreased pulse.
Correct Answer: A
Rationale: The correct answer is A: Decreased blood pressure. Metoprolol is a beta-blocker that works by reducing heart rate and decreasing the workload on the heart, leading to a decrease in blood pressure. This is a therapeutic effect as it helps manage conditions like hypertension and angina.
Incorrect choices:
B: Decreased dysrhythmias - While metoprolol can help reduce dysrhythmias, the primary therapeutic effect is on blood pressure.
C: Increased urine output - Metoprolol does not directly affect urine output.
D: Decreased pulse - Decreasing pulse is a common side effect of metoprolol, but the therapeutic effect is primarily on blood pressure.
A nurse is caring for a client who is receiving heat applications using an aquathermia pad. Which of the following actions should the nurse take when applying the pad?
- A. Leave the pad in place for at least 40 minutes
- B. Set the pad’s temperature to 42.2°C (108°F)
- C. Use safety pins to keep the pad in place
- D. Stop the treatment if the client’s skin becomes red
Correct Answer: D
Rationale: The correct answer is D: Stop the treatment if the client’s skin becomes red. This is important because redness indicates potential skin damage or burns due to excessive heat exposure. It is crucial to monitor the client's skin during heat application to prevent harm. Choice A is incorrect because leaving the pad in place for a specific duration can lead to skin damage if the temperature is too high. Choice B is incorrect as setting the pad's temperature too high can cause burns. Choice C is incorrect as safety pins can cause injury or discomfort to the client. Therefore, the correct action is to closely monitor the client's skin for any signs of redness and stop the treatment immediately if redness occurs to prevent further harm.
A nurse is caring for a client who has benign prostatic hyperplasia (BPH). The nurse should expect which of the following findings?
- A. Painful urination
- B. Urge incontinence
- C. Critically elevated prostate-specific antigen (PSA) level
- D. Difficulty starting the flow of urine
Correct Answer: D
Rationale: The correct answer is D: Difficulty starting the flow of urine. This is an expected finding in a client with benign prostatic hyperplasia (BPH) due to the enlargement of the prostate gland, which can obstruct the urethra and impede the flow of urine. This commonly leads to hesitancy or difficulty initiating urination.
- A: Painful urination is not typically associated with BPH, as it is more commonly seen in conditions like urinary tract infections.
- B: Urge incontinence is not a typical finding in BPH; it is more commonly seen in conditions like overactive bladder.
- C: Critically elevated prostate-specific antigen (PSA) levels are not a direct symptom of BPH but may be used for screening and monitoring prostate cancer.
In summary, difficulty starting the flow of urine is the most relevant finding in BPH due to the mechanical obstruction caused by the enlarged prostate gland.