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An older client with cirrhosis of the liver and hepatic failure is placed on a low sodium diet and is receiving periodic albumin infusions. Which assessment finding indicates progress toward the desired effect of this treatment plan?
- A. Clear, dark amber-colored urine.
- B. Improved level of consciousness.
- C. Prothrombin time within normal limits.
- D. Decreased abdominal girth.
Correct Answer: D
Rationale: Decreased abdominal girth reflects reduced ascites, confirming the effectiveness of low sodium diet and albumin infusions in managing fluid retention in hepatic failure.
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Which admission assessment findings should the nurse document related to a client who has been diagnosed with Cushing's syndrome?
- A. Husky voice and complaints of hoarseness.
- B. Warm, soft, moist, salmon-colored skin.
- C. Visible swelling of the neck, with no pain.
- D. Central-type obesity, with thin extremities.
Correct Answer: D
Rationale: Central-type obesity with thin extremities is a hallmark of Cushing's syndrome due to cortisol-induced fat redistribution and muscle wasting, making it a key finding to document.
A client with sickle cell anemia develops a fever during the last hour of administration of a unit of packed red blood cells. When notifying the healthcare provider, which information should the nurse provide first using the SBAR (Situation, Background, Assessment, and Recommendation) communication process?
- A. Explain specific reason for urgent notification.
- B. Obtain a PRN prescription for acetaminophen for fever over 101° F (38.3° C).
- C. Preface the report by stating the client's name and admitting diagnosis.
- D. Communicate the pre-transfusion temperatures.
Correct Answer: C
Rationale: Per SBAR, starting with the client's name and diagnosis establishes identity and context, ensuring clear communication before detailing the situation, background, assessment, and recommendation.
The nurse is caring for a client with chemotherapy-induced mucositis who is describing soreness of the tongue and oral issues. Which is the best initial nursing action?
- A. Cleanse the tongue and mouth with swabs.
- B. Administer a topical analgesic per protocol.
- C. Obtain a soft diet for the client.
- D. Encourage frequent mouth care.
Correct Answer: B
Rationale: Administering a topical analgesic provides immediate pain relief for mucositis, addressing the client's discomfort first before implementing other supportive measures like diet or mouth care.
The nurse is caring for a client who is still experiencing light sedation after undergoing an emergency colectomy for bowel obstruction. Which postoperative pain intervention should the nurse implement first?
- A. Provide the first medication prescribed for pain management.
- B. Review medical records to obtain pain tolerance expectations.
- C. Wait until the client is awake before providing pain management.
- D. Attempt to obtain a self-report of pain level from the client.
Correct Answer: A
Rationale: Providing the prescribed pain medication first prevents pain escalation in a sedated client, using behavioral indicators like vital signs to guide administration, as self-reporting may be unreliable.
A male client with diabetes mellitus (DM) is transferred from the hospital to a rehabilitation facility following treatment for a stroke with resulting right hemiplegia. The client reports his feet feel uncomfortably cool at night, preventing him from falling asleep. Which action should the nurse implement?
- A. Use a bed cradle to hold the covers off feet.
- B. Provide a warming pad (Aqua-pad or K-pad) to feet.
- C. Place warm blankets next to the client's feet.
- D. Medicate the client with a prescribed sedative.
Correct Answer: B
Rationale: A warming pad improves blood flow to the feet, addressing coolness due to diabetic neuropathy and poor circulation, while minimizing risks like burns in a client with reduced sensation.