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The healthcare provider is assessing a client with left-sided heart failure. Which laboratory value should be closely monitored?
- A. Serum sodium level
- B. Serum potassium level
- C. Serum creatinine level
- D. Serum glucose level
Correct Answer: B
Rationale: In a client with left-sided heart failure, monitoring serum potassium levels is crucial. This helps in assessing kidney function and fluid balance. Elevated potassium levels can result from impaired kidney function, which is common in heart failure. Monitoring sodium levels (choice A) is important in heart failure but not specifically related to left-sided heart failure. Serum creatinine (choice C) reflects kidney function but is not the most critical value to monitor in this case. Serum glucose level (choice D) is important but not the priority when assessing left-sided heart failure.
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A client with rapid respirations and audible rhonchi is admitted to the intensive care unit because of a pulmonary embolism (PE). Low-flow oxygen by nasal cannula and weight-based heparin protocol are initiated. Which intervention is most important for the nurse to include in this client's plan of care?
- A. Evaluate blood clotting factors daily.
- B. Encourage incentive spirometry use.
- C. Administer pain medication as needed.
- D. Monitor for signs of bleeding.
Correct Answer: A
Rationale: Evaluating blood clotting factors daily is crucial when a client is on heparin therapy to monitor for potential complications such as bleeding or clotting issues. This monitoring helps ensure that the heparin dose is within the therapeutic range and reduces the risk of bleeding or clotting complications. Encouraging incentive spirometry use is beneficial for preventing atelectasis and improving lung function, but in this scenario, monitoring blood clotting factors takes precedence. Administering pain medication as needed is important for the client's comfort but is not the priority in managing a pulmonary embolism. Monitoring for signs of bleeding is important due to heparin therapy, but evaluating blood clotting factors provides more specific information on the client's response to treatment.
A client with newly diagnosed peptic ulcer disease is being taught about lifestyle modifications. Which client statement indicates that further teaching is needed?
- A. 'I should avoid eating spicy foods to prevent irritation of my ulcer.'
- B. 'I should take my antacids regularly, even if I don't have symptoms.'
- C. 'I should avoid smoking to prevent exacerbation of my symptoms.'
- D. 'I should avoid drinking alcohol to prevent irritation of my ulcer.'
Correct Answer: D
Rationale: The corrected question assesses the client's understanding of lifestyle modifications for peptic ulcer disease. Choice D, 'I should avoid drinking alcohol to prevent irritation of my ulcer,' is the correct answer. This statement demonstrates that the client has a good grasp of the teaching provided, as alcohol can indeed irritate peptic ulcers. Choices A, B, and C are all accurate statements that reflect appropriate understanding of managing peptic ulcer disease and do not indicate a need for further teaching.
While removing staples from a male client's postoperative wound site, the nurse observes that the client's eyes are closed and his face and hands are clenched. The client states, 'I just hate having staples removed.' After acknowledging the client's anxiety, what action should the nurse implement?
- A. Attempt to distract the client with general conversation
- B. Administer a pain medication
- C. Continue with the procedure while reassuring the client
- D. Stop the procedure and notify the healthcare provider
Correct Answer: A
Rationale: In this situation, the nurse should attempt to distract the client with general conversation. Distracting the client can help reduce anxiety and make the procedure less stressful. Administering pain medication (choice B) is not appropriate as the client's discomfort is related to anxiety, not physical pain. Continuing with the procedure while reassuring the client (choice C) may not address the client's anxiety effectively. Stopping the procedure and notifying the healthcare provider (choice D) is not necessary at this point since the client's anxiety can be managed by attempting to distract him.
A female client with type 2 diabetes reports that she has been taking her medications as prescribed but her blood glucose levels remain elevated. Which action should the nurse take first?
- A. Check the client's current blood glucose level.
- B. Assess the client's diet and medication adherence.
- C. Review the client's medication list for potential interactions.
- D. Obtain a hemoglobin A1c level.
Correct Answer: C
Rationale: The correct action the nurse should take first is to review the client's medication list for potential interactions. This step is crucial as it can help identify any medications that might be contributing to the elevated blood glucose levels. Checking the current blood glucose level (choice A) is important but not the first action to address the ongoing issue. Assessing the client's diet and medication adherence (choice B) is also important, but reviewing the medication list should be the initial step to rule out any drug-related causes. Obtaining a hemoglobin A1c level (choice D) is a valuable assessment but may not address the immediate need to identify potential medication interactions.
The practical nurse (PN) is assigned to work with three registered nurses (RNs) who are caring for neurologically compromised clients. The client with which change in status is best to assign to the PN?
- A. Diabetic ketoacidosis with a Glasgow Coma Scale score change from 10 to 7.
- B. Myxedema coma with a blood pressure change from 80/50 to 70/40.
- C. Viral meningitis with a temperature change from 101°F to 102°F.
- D. Subdural hematoma with a blood pressure change from 150/80 to 170/60.
Correct Answer: C
Rationale: The client with viral meningitis and a temperature change is the most stable and appropriate for assignment to the PN. A change in temperature from 101°F to 102°F is not as critical as changes in Glasgow Coma Scale score, blood pressure, or wider blood pressure variations. The other clients require more complex monitoring and intervention due to their critical changes in status.