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After successful resuscitation, a client is given propranolol and transferred to the Intensive Coronary Care Unit (ICCU). On admission, magnesium sulfate 4 grams IV in 250 ml D5W at one gram/hour. Which assessment findings require immediate intervention by the nurse?
- A. Dark amber urine draining via an indwelling catheter at a rate of 40 ml per hour
- B. Serum calcium of 9.0 mg/dl (2.2 mmol/L SI) and magnesium of 1.8 mg/dl or Eq/L (0.74 mmol/L SI)
- C. Sinus rhythm at 72 beats/minute and peripheral blood pressure of 99/62
- D. Respiratory rate of 10 breaths per minute
Correct Answer: D
Rationale: The correct answer is D. A low respiratory rate of 10 breaths per minute is indicative of possible magnesium toxicity, which can be a serious condition requiring immediate intervention. It is a critical finding that needs prompt attention to prevent further complications. The other options are not as urgent: A - dark amber urine may indicate dehydration but does not require immediate intervention, B - serum calcium and magnesium levels are within normal limits, C - sinus rhythm and blood pressure values are also within normal range and do not require immediate action.
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The nurse notes that a depressed female client has been more withdrawn and non-communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?
- A. Encourage the client's family to visit more often
- B. Schedule a daily conference with the social worker
- C. Encourage the client to participate in group activities
- D. Engage the client in a non-threatening conversation
Correct Answer: D
Rationale: Engaging the client in a non-threatening conversation is crucial as it can help build trust and provide support, addressing the client's withdrawal. This intervention focuses on establishing a therapeutic relationship and giving the client an opportunity to express their feelings. Choices A, B, and C do not directly target the client's need for communication and may not address the underlying issues contributing to her withdrawal. Encouraging the client's family to visit more often (Choice A) may add pressure or discomfort to the client. Scheduling a daily conference with the social worker (Choice B) may not address the client's immediate need for communication. Encouraging the client to participate in group activities (Choice C) may be overwhelming for the client and not address her withdrawal directly.
What should the nurse monitor for during the IV infusion of vasopressin (Pitressin) in a client with bleeding esophageal varices?
- A. Vasodilatation of the extremities
- B. Chest pain and dysrhythmia
- C. Hypotension and tachycardia
- D. Decreasing GI cramping and nausea
Correct Answer: B
Rationale: During the IV infusion of vasopressin in a client with bleeding esophageal varices, the nurse should monitor for chest pain and dysrhythmia. Vasopressin is a vasoconstrictor that can cause cardiovascular effects, including chest pain and dysrhythmias. Options A, C, and D are incorrect as vasopressin is not expected to cause vasodilatation of the extremities, hypotension, tachycardia, or improvements in GI symptoms such as cramping and nausea.
A client with a peripherally inserted central catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform?
- A. Observe the PICC line site for inflammation.
- B. Encourage increasing fluid intake.
- C. Monitor blood pressure regularly.
- D. Assess skin turgor for dehydration.
Correct Answer: A
Rationale: The correct answer is to observe the PICC line site for inflammation. When a client with a PICC line develops a fever, it could indicate an infection related to the catheter. Assessing the PICC line site for signs of inflammation, such as redness, warmth, swelling, or drainage, is crucial in identifying a potential infection early. Choice B is incorrect because increasing fluid intake is not directly related to assessing a PICC line for infection. Choice C is not the most appropriate assessment in this situation as monitoring blood pressure may not directly help in identifying the cause of the fever. Choice D is unrelated to the assessment of a fever in a client with a PICC line.
A young adult male who is being seen at the employee health care clinic for an annual assessment tells the nurse that his mother was diagnosed with schizophrenia when she was his age and that life with a schizophrenic mother was difficult indeed. Which response is best for the nurse to provide?
- A. Ask the client if he is worried about becoming schizophrenic at the age his mother was diagnosed.
- B. Encourage the client to seek genetic counseling to determine his risk for mental illness.
- C. Inform the client that his mother's schizophrenia has affected his psychological development.
- D. Tell the client that mental illness has a familial predisposition so he should see a psychiatrist.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with multiple sclerosis is experiencing scotomas (blind spots), which are limiting peripheral vision. What intervention should the nurse include in this client's plan of care?
- A. Encourage the use of corrective lenses during the day
- B. Practice visual exercises that focus on a still object
- C. Alternate an eye patch from eye every 2 hours
- D. Teach techniques for scanning the environment
Correct Answer: D
Rationale: The correct intervention for a client with multiple sclerosis experiencing scotomas and limited peripheral vision is to teach techniques for scanning the environment. This intervention helps the client compensate for vision loss by learning how to scan and explore their surroundings effectively. Encouraging the use of corrective lenses may not address the issue of scotomas, and visual exercises focusing on a still object may not enhance peripheral vision. Alternating an eye patch every 2 hours is not typically indicated for scotomas in multiple sclerosis, making it an incorrect choice.