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An older woman with end-stage heart disease is hospitalized for severe heart failure. She is alert, oriented, and requests that no heroic measures are implemented if her breathing stops. What action should the nurse take first?
- A. Consult the palliative care team about the client's care.
- B. Set up a family conference to discuss the client's wishes.
- C. Discuss with the client her meaning of heroic measures.
- D. Obtain a 'do not resuscitate' (DNR) prescription.
Correct Answer: C
Rationale: Clarifying 'heroic measures' ensures client wishes are understood.
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The nurse assesses that a client who is disoriented drank eight glasses of water in two hours and is continuing to drink excessive amounts of water. Because the nurse is concerned about water intoxication, which laboratory value should the nurse monitor?
- A. White blood cell count.
- B. Serum sodium levels.
- C. Serum potassium levels.
- D. Creatinine clearance.
Correct Answer: B
Rationale: Excess water dilutes sodium, risking hyponatremia.
The nurse retrieves hydromorphone 4 mg/mL from an automated dispensing system, for a client who is receiving hydromorphone 3 mg IM every 6 hours PRN for severe pain. How many mL should the nurse administer to the client? (Enter the numerical value only. If rounding is required, round to the nearest tenth.)
Correct Answer: 0.8
Rationale: 3 mg ÷ 4 mg/mL = 0.75 mL, rounded to 0.8 mL.
The healthcare provider prescribes two doses of an antihypertensive medication for a client. Before administering the second dose, the nurse obtains a blood pressure measurement of 80/50 mm Hg. Which action should the nurse take?
- A. Position the client in a lateral lying position.
- B. Document the blood pressure and monitor the client.
- C. Encourage an increase in oral fluid intake.
- D. Hold the medication and notify the healthcare provider.
Correct Answer: D
Rationale: Holding medication prevents worsening hypotension.
The nurse is preparing a bladder irrigation for an adult client who has a long-term indwelling urinary catheter. The urine is cloudy with fibrin clots and sediment. Which intervention should the nurse implement?
- A. Power flush with 60 mL to remove mucous obstructions.
- B. Slowly irrigate catheter with saline using an infusion pump.
- C. Clamp the catheter for 30 minutes prior to irrigating.
- D. Use a sterile syringe to irrigate with 20 mL normal saline.
Correct Answer: B
Rationale: Slow irrigation safely clears clots and sediment.
The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?
- A. Tennis shoes with velcro.
- B. Rubber-soled slippers.
- C. Slip-on rubber shower shoes.
- D. Leather-soled loafers.
Correct Answer: A
Rationale: Velcro tennis shoes provide support and stability.