Nokea
An elderly client with congestive heart failure (CHF) is admitted to the hospital. Which laboratory test result should the nurse expect to find?
- A. Elevated serum sodium level.
- B. Decreased brain natriuretic peptide (BNP) level.
- C. Increased serum creatinine level.
- D. Elevated hemoglobin and hematocrit levels.
Correct Answer: C
Rationale: The correct answer is C, increased serum creatinine level. In CHF, the heart's reduced pumping ability can lead to decreased blood flow to the kidneys, resulting in impaired kidney function. This can cause an elevation in serum creatinine level, indicating decreased kidney function. Elevated serum sodium level (A) is not typically seen in CHF, as patients often have fluid retention leading to dilutional hyponatremia. Decreased BNP level (B) is not expected in CHF, as BNP is released in response to increased ventricular stretching and volume overload. Elevated hemoglobin and hematocrit levels (D) are not directly related to CHF; they may be seen in conditions like dehydration or chronic hypoxia, but not specifically in CHF.
You may also like to solve these questions
What dietary advice should the nurse provide to help reduce the occurrence of hot flashes in a post-menopausal client?
- A. Increase intake of spicy foods.
- B. Limit caffeine and alcohol consumption.
- C. Consume a high-protein diet.
- D. Eat more dairy products.
Correct Answer: B
Rationale: The correct answer is B: Limit caffeine and alcohol consumption. Hot flashes can be triggered by stimulants like caffeine and alcohol. Limiting intake can help reduce their occurrence. Increasing spicy foods (A) can actually worsen hot flashes. High-protein diets (C) and consuming more dairy products (D) do not have a direct impact on hot flashes.
A client is admitted with suspected meningitis. Which assessment finding requires immediate intervention?
- A. Headache.
- B. Fever.
- C. Nuchal rigidity.
- D. Seizures.
Correct Answer: D
Rationale: The correct answer is D: Seizures. Seizures in a patient with suspected meningitis indicate increased intracranial pressure, which is a medical emergency requiring immediate intervention to prevent brain damage or herniation. Headache (A), fever (B), and nuchal rigidity (C) are common symptoms of meningitis but do not pose an immediate threat to life like seizures do. Addressing the seizures first is crucial to prevent further complications and ensure the patient's safety.
What instruction should be provided to a client with a history of myocardial infarction (MI) who is prescribed nitroglycerin?
- A. Take nitroglycerin with food to avoid stomach upset.
- B. Store nitroglycerin tablets in a dark, glass container.
- C. Swallow nitroglycerin tablets whole without chewing.
- D. Discontinue the medication if a headache occurs.
Correct Answer: B
Rationale: The correct answer is B because nitroglycerin tablets should be stored in a dark, glass container to protect them from light and moisture, which could decrease their effectiveness. Storing them in any other container could lead to degradation of the medication.
Choice A is incorrect because nitroglycerin should be taken sublingually, not with food. Choice C is incorrect because nitroglycerin should be placed under the tongue to be absorbed quickly, not swallowed whole. Choice D is incorrect because experiencing a headache is a common side effect of nitroglycerin and does not indicate that the medication should be discontinued.
Which client's laboratory value requires immediate intervention by a nurse?
- A. A client with GI bleeding who is receiving a blood transfusion and has a hemoglobin of 7 grams.
- B. A client with pancreatitis who has a fasting glucose of 190 mg/dl today and had 160 mg/dl yesterday.
- C. A client with hepatitis who is jaundiced and has a bilirubin level that is 4 times the normal value.
- D. A client with cancer who has an absolute neutrophil count < 500 today and had 2,000 yesterday.
Correct Answer: D
Rationale: The correct answer is D because a client with an absolute neutrophil count < 500 is at high risk for serious infections due to severe neutropenia. Neutrophils are crucial for fighting infections, and a low count puts the client at immediate risk. Therefore, intervention is required to prevent life-threatening complications.
Choice A: A hemoglobin of 7 grams in a client with GI bleeding receiving a blood transfusion indicates anemia, but it does not require immediate intervention unless the client is symptomatic.
Choice B: A fasting glucose of 190 mg/dl in a client with pancreatitis is elevated but does not require immediate intervention unless the client is symptomatic or experiencing complications.
Choice C: A bilirubin level 4 times the normal value in a jaundiced client with hepatitis is concerning but does not require immediate intervention unless there are signs of severe liver dysfunction or complications.
A client with type 2 diabetes mellitus is prescribed metformin (Glucophage). Which instruction should the nurse provide?
- A. Take the medication on an empty stomach.
- B. Limit your fluid intake while on this medication.
- C. Monitor your blood glucose levels regularly.
- D. Avoid eating foods high in potassium.
Correct Answer: C
Rationale: The correct answer is C: Monitor your blood glucose levels regularly. This is important because metformin helps lower blood sugar levels, and monitoring glucose levels helps ensure the medication is effective and the client is not experiencing hypoglycemia or hyperglycemia. Option A is incorrect because metformin should be taken with meals to reduce gastrointestinal side effects. Option B is incorrect as metformin does not typically require fluid restriction. Option D is incorrect as metformin does not affect potassium levels. Regularly monitoring blood glucose levels is crucial for managing type 2 diabetes effectively.