Nokea
The healthcare provider is assessing a client who has just received anesthesia. What is the most critical finding to report to the healthcare provider?
- A. Client reports dizziness
- B. Client has a drop in blood pressure
- C. Client experiences mild nausea
- D. Client reports dry mouth
Correct Answer: B
Rationale: A significant drop in blood pressure following anesthesia could indicate a serious reaction, such as hypovolemia or anesthetic-induced hypotension. This requires immediate medical attention, while other symptoms like dizziness, mild nausea, and dry mouth are more common and less critical. Dizziness could be expected due to the effects of anesthesia, mild nausea is a common side effect, and dry mouth is a known effect of anesthesia as well.
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The client has been diagnosed with hypertension, and the nurse is providing education on dietary changes. Which food should the client be advised to avoid?
- A. Bananas
- B. Processed meats
- C. Low-fat yogurt
- D. Whole grains
Correct Answer: B
Rationale: Processed meats should be avoided by clients with hypertension as they are high in sodium, which can contribute to elevated blood pressure. It is essential to limit the intake of high-sodium foods to help manage hypertension. Bananas, low-fat yogurt, and whole grains are generally beneficial for heart health due to their nutrient content and should not be avoided in a heart-healthy diet.
A client with chronic liver disease develops jaundice. What is the most important assessment the nurse should perform?
- A. Assess the client's skin for lesions or sores.
- B. Monitor the client's liver function tests.
- C. Assess for changes in mental status and behavior.
- D. Monitor the client's urine output closely.
Correct Answer: D
Rationale: In a client with chronic liver disease developing jaundice, the most important assessment the nurse should perform is to monitor the client's urine output closely. Jaundice can indicate worsening liver function, so monitoring urine output helps assess kidney function and fluid balance, which are critical in chronic liver disease. Assessing the client's skin for lesions or sores (Choice A) may be relevant for dermatological conditions but is not the priority in this case. Monitoring liver function tests (Choice B) is important but may not provide immediate information on the client's current status. Assessing for changes in mental status and behavior (Choice C) is important for detecting hepatic encephalopathy but does not directly address the immediate concern of fluid balance and kidney function in the presence of jaundice.
A client is diagnosed with chronic renal failure, and the nurse is teaching dietary modifications. What should be limited in this client's diet?
- A. Carbohydrates
- B. Fats
- C. Proteins
- D. Vitamins
Correct Answer: C
Rationale: In chronic renal failure, proteins should be limited in the diet. When the kidneys are not functioning well, the buildup of protein byproducts can put additional stress on them. Limiting protein intake can help reduce the burden on the kidneys. Carbohydrates and fats do not need to be restricted in the same way as proteins. Vitamins are essential nutrients that should not be limited in the diet unless specified by a healthcare provider for a specific reason.
When assessing an IV site used for fluid replacement and medication administration, the client complains of tenderness when the arm is touched above the site. Which additional assessment finding warrants immediate intervention by the nurse?
- A. Cool skin at the IV insertion site
- B. Presence of fluid leaking around the IV catheter
- C. Swelling above the IV site
- D. Red streaks tracking the vein
Correct Answer: D
Rationale: The correct answer is D: "Red streaks tracking the vein." Red streaks indicate phlebitis, an inflammation of the vein that can lead to serious complications like infection or thrombophlebitis. Immediate intervention is required to prevent further damage. Choice A, cool skin at the IV insertion site, could indicate decreased circulation but is not as urgent as addressing phlebitis. Choice B, presence of fluid leaking around the IV catheter, may indicate infiltration or dislodgement of the catheter, requiring intervention but not as urgently as phlebitis. Choice C, swelling above the IV site, may suggest localized inflammation but doesn't pose an immediate threat like phlebitis does.
The nurse is assessing a client with a history of schizophrenia who reports feeling sedated after starting a new antipsychotic medication. Which intervention is most appropriate?
- A. Reassure the client that sedation will subside with continued use
- B. Instruct the client to take the medication at bedtime
- C. Teach the client to take the medication with food
- D. Consult the healthcare provider to reduce the dosage
Correct Answer: B
Rationale: Instructing the client to take the medication at bedtime is the most appropriate intervention. Taking antipsychotic medications at bedtime can help reduce the impact of sedation on the client's daily activities. This approach allows the client to sleep through the sedative effects. Choice A is incorrect because just reassuring the client may not address the immediate issue of sedation. Choice C is incorrect as taking the medication with food does not directly address the sedation concern. Choice D is not the first-line intervention; adjusting the dosage should be done by the healthcare provider after assessing the client's response to the medication.