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The healthcare provider is assessing a client with left-sided heart failure. Which laboratory value should be monitored closely?
- A. Serum sodium of 135 mEq/L
- B. Serum potassium of 4.5 mEq/L
- C. Serum creatinine of 1.8 mg/dl
- D. Serum glucose of 200 mg/dl
Correct Answer: C
Rationale: In a client with left-sided heart failure, monitoring serum creatinine is crucial to evaluate kidney function and fluid balance. Elevated creatinine levels can indicate impaired kidney function, which is common in heart failure due to decreased cardiac output and renal perfusion. Serum sodium levels (choice A) are important but are more closely associated with fluid balance and heart failure exacerbation. Serum potassium (choice B) is also important to monitor, but it is more closely linked to cardiac arrhythmias rather than kidney function. Serum glucose levels (choice D) are significant but are not the priority for monitoring in left-sided heart failure.
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An adult client comes to the clinic and reports his concern over a lump that 'just popped up on my neck about a week ago.' In performing an examination of the lump, the nurse palpates a large, non-tender, hardened left subclavian lymph node. There is no overlying tissue inflammation. What do these findings suggest?
- A. Malignancy
- B. Infection
- C. Benign cyst
- D. Lymphadenitis
Correct Answer: A
Rationale: The findings of a large, non-tender, hardened lymph node, especially in the absence of overlying tissue inflammation, are indicative of malignancy. These characteristics raise suspicion for cancer, prompting the need for further investigation. Choice B, Infection, is incorrect because infection would typically present as a tender and possibly swollen lymph node. Choice C, Benign cyst, is incorrect as cysts are usually soft and movable. Choice D, Lymphadenitis, is incorrect as lymphadenitis usually presents with tender and enlarged lymph nodes in response to an infection.
The nurse notes that a client who has undergone a thoracotomy has an increase in a large amount of dark red blood in the chest tube collection chamber. What action should the nurse take?
- A. Document the findings for this procedure as expected
- B. Notify the healthcare provider immediately
- C. Check the tube for kinks or dependent loops
- D. Increase the suction to the chest drainage system
Correct Answer: B
Rationale: An increase in a large amount of dark red blood in the chest tube collection chamber may indicate active bleeding. The nurse should notify the healthcare provider immediately to address the situation promptly and prevent further complications. Documenting the findings without taking immediate action could delay necessary interventions. Checking the tube for kinks or dependent loops is a good practice but not the priority when dealing with a potentially life-threatening situation like active bleeding. Increasing the suction without healthcare provider's orders can lead to complications and is not appropriate in this scenario.
A client with a history of myocardial infarction is admitted with chest pain. Which diagnostic test should the nurse anticipate preparing the client for first?
- A. Electrocardiogram (ECG)
- B. Chest X-ray
- C. Arterial blood gases (ABGs)
- D. Echocardiogram
Correct Answer: A
Rationale: The correct answer is A: Electrocardiogram (ECG). An electrocardiogram should be performed first to assess for cardiac ischemia in a client with a history of myocardial infarction and chest pain. This test provides immediate information about the heart's electrical activity. Choice B, Chest X-ray, is used to visualize the structures of the chest, including the heart and lungs, but it does not directly assess for cardiac ischemia. Choice C, Arterial blood gases (ABGs), measures the oxygen and carbon dioxide levels in the blood and assesses acid-base balance, which is not the primary concern in this scenario. Choice D, Echocardiogram, is an ultrasound of the heart that provides information about the heart's structure and function, but it is not the initial diagnostic test for assessing cardiac ischemia in this situation.
A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. Which intervention should the nurse implement first?
- A. Administer oxygen therapy as prescribed.
- B. Elevate the head of the bed.
- C. Assess the client's level of consciousness.
- D. Obtain a sputum culture.
Correct Answer: A
Rationale: Administering oxygen therapy as prescribed is the initial priority when managing an exacerbation of COPD. In COPD exacerbations, the primary concern is hypoxemia due to impaired gas exchange. Administering oxygen helps to improve oxygenation and prevent further complications. Elevating the head of the bed can aid in breathing comfort but is not the priority over ensuring adequate oxygen supply. Assessing the client's level of consciousness is important but comes after ensuring oxygenation. Obtaining a sputum culture is relevant for identifying pathogens but is not the immediate priority in addressing hypoxemia.
A client with a spinal cord injury is admitted to the ICU. Which nursing intervention is most important to include in this client's plan of care?
- A. Monitor for signs of autonomic dysreflexia.
- B. Implement measures to prevent pressure ulcers.
- C. Perform passive range of motion exercises.
- D. Ensure that the client is turned every two hours.
Correct Answer: A
Rationale: The correct answer is A: Monitor for signs of autonomic dysreflexia. Autonomic dysreflexia is a life-threatening condition that can occur in clients with spinal cord injuries, especially those with injuries above the T6 level. It is characterized by a sudden onset of excessively high blood pressure, pounding headache, profuse sweating, and flushing above the level of injury. Failure to recognize and treat autonomic dysreflexia promptly can lead to seizures, stroke, or even death. Therefore, monitoring for signs of autonomic dysreflexia is crucial in clients with spinal cord injuries. Choices B, C, and D are important interventions too, but in the context of a spinal cord injury, monitoring for autonomic dysreflexia takes priority due to its potentially life-threatening nature.