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The healthcare professional is caring for a client with a chest tube following a thoracotomy. Which assessment finding requires immediate intervention?
- A. Continuous bubbling in the water seal chamber.
- B. Serosanguineous drainage in the collection chamber.
- C. Intermittent bubbling in the suction control chamber.
- D. Chest tube secured to the client's chest wall.
Correct Answer: A
Rationale: The correct answer is A: Continuous bubbling in the water seal chamber. Continuous bubbling in the water seal chamber indicates an air leak in the system, which can lead to pneumothorax or compromised lung function. Immediate intervention is required to prevent complications. Serosanguineous drainage in the collection chamber (B) is expected after thoracotomy. Intermittent bubbling in the suction control chamber (C) is normal and indicates proper suction function. Chest tube secured to the client's chest wall (D) is essential for stability and should not require immediate intervention.
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A client with newly diagnosed hypertension is prescribed enalapril (Vasotec). Which instruction should the nurse provide to the client?
- A. Increase your intake of potassium-rich foods.
- B. Report any persistent cough to your healthcare provider.
- C. Take the medication with a full meal.
- D. Avoid grapefruit juice while taking this medication.
Correct Answer: B
Rationale: The correct answer is B: Report any persistent cough to your healthcare provider. Enalapril is an ACE inhibitor that can cause a dry, persistent cough as a side effect. This cough can be a sign of a serious condition called angioedema. Therefore, it is crucial for the client to report any cough to their healthcare provider promptly to assess and manage it.
Incorrect choices:
A: Increasing intake of potassium-rich foods is not necessary when taking enalapril, as it does not typically cause potassium imbalances.
C: Enalapril can be taken with or without food, so taking it with a full meal is not a specific instruction.
D: Avoiding grapefruit juice is typically recommended for medications metabolized by the CYP3A4 enzyme, which enalapril is not.
A client with cirrhosis of the liver is experiencing pruritus. Which intervention should the nurse implement to help relieve the client's symptoms?
- A. Administer acetaminophen (Tylenol).
- B. Apply lotion to the skin.
- C. Encourage a high-protein diet.
- D. Provide a warm bath.
Correct Answer: B
Rationale: The correct answer is B: Apply lotion to the skin. Pruritus in cirrhosis is often due to dry skin. Applying lotion helps hydrate the skin, reducing itching. Acetaminophen (A) can worsen liver damage. High-protein diet (C) is not directly related to pruritus relief. Warm bath (D) may further dry the skin.
A client with chronic renal failure is scheduled to receive epoetin alfa (Epogen). Which laboratory result should the nurse review before administering the medication?
- A. Blood urea nitrogen (BUN)
- B. Creatinine clearance
- C. Hemoglobin level
- D. Serum potassium
Correct Answer: C
Rationale: The correct answer is C: Hemoglobin level. In chronic renal failure, the kidneys may not produce enough erythropoietin, leading to anemia. Epoetin alfa stimulates red blood cell production. Therefore, reviewing the hemoglobin level is crucial to determine the need for the medication.
Incorrect choices:
A: Blood urea nitrogen (BUN) and B: Creatinine clearance are indicators of kidney function but not directly related to monitoring the effectiveness of epoetin alfa.
D: Serum potassium is important in renal failure but not specifically needed to review before administering epoetin alfa.
A client with a history of hypertension is prescribed hydrochlorothiazide. Which instruction should the nurse include in the client's teaching?
- A. Take this medication in the morning.
- B. Avoid foods high in potassium.
- C. Monitor your blood pressure regularly.
- D. Decrease your intake of high-sodium foods.
Correct Answer: C
Rationale: The correct answer is C: "Monitor your blood pressure regularly." This instruction is crucial for a client with hypertension prescribed hydrochlorothiazide because the medication helps lower blood pressure. By monitoring their blood pressure regularly, the client can track the effectiveness of the medication and ensure it is within the target range. This allows for early detection of any potential issues or the need for medication adjustments.
Option A is incorrect because while it is generally recommended to take hydrochlorothiazide in the morning, it is not the most critical instruction for this scenario. Option B is incorrect as hydrochlorothiazide can cause hypokalemia, so avoiding high potassium foods is not necessary. Option D is also important but not as crucial as monitoring blood pressure, as reducing high-sodium foods can help manage hypertension but is not specific to hydrochlorothiazide.
A client with deep vein thrombosis (DVT) is receiving heparin therapy. Which laboratory test should the nurse monitor to assess the effectiveness of the therapy?
- A. Prothrombin time (PT)
- B. Platelet count
- C. Activated partial thromboplastin time (aPTT)
- D. International normalized ratio (INR)
Correct Answer: C
Rationale: The correct answer is C: Activated partial thromboplastin time (aPTT). The aPTT measures the effectiveness of heparin therapy by assessing the clotting time. In patients with DVT receiving heparin, the goal is to keep the aPTT within a therapeutic range to prevent clot formation. Monitoring aPTT helps ensure the dose of heparin is appropriate.
Prothrombin time (PT) and International normalized ratio (INR) are used to monitor warfarin therapy, not heparin. Platelet count is important to monitor for heparin-induced thrombocytopenia but does not directly assess the effectiveness of heparin therapy for DVT.