Nokea
Which findings indicate the client's condition has improved? (Select all that apply)
- A. Pain level
- B. Respiratory rate
- C. Heart rate
- D. Blood pressure
- E. Echocardiogram results
- F. Urinary Output
- G. Oxygenation Saturation
Correct Answer: A, B
Rationale: The correct answers are A and B. Pain level indicates the client's subjective improvement, while respiratory rate reflects their physiological status. Pain reduction suggests improved comfort and possibly better overall health, while a decrease in respiratory rate may indicate improved oxygenation and reduced stress. Choices C, D, E, F, and G are not directly linked to the client's overall condition improvement as they can vary for several reasons, independent of the client's actual health status.
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A nurse is caring for a client who is experiencing an increase in intracranial pressure (ICP). The nurse should expect which of the following as an early manifestation of increased ICP?
- A. Projectile vomiting
- B. Decorticate posturing
- C. Restlessness
- D. Papilledema
Correct Answer: C
Rationale: The correct answer is C: Restlessness. In early stages of increased ICP, the brain tries to compensate by increasing blood flow to maintain perfusion, leading to restlessness. Projectile vomiting (A) is a late sign due to pressure on the vomiting center. Decorticate posturing (B) and papilledema (D) are late signs of increased ICP.
A nurse is assessing a client who has a chest tube connected to a closed water-seal drainage system. Which of the following findings should the nurse report to the provider?
- A. Constant bubbling in the water seal chamber
- B. Intermittent bubbling in the suction chamber
- C. Clear drainage of 50 mL over 8 hours
- D. Mild pain at the insertion site
Correct Answer: A
Rationale: The correct answer is A: Constant bubbling in the water seal chamber. Constant bubbling in the water seal chamber indicates an air leak in the chest tube system, which can lead to lung collapse or pneumothorax. This finding should be reported to the provider immediately for further evaluation and intervention. Intermittent bubbling in the suction chamber (choice B) is expected and indicates that the suction is working properly. Clear drainage of 50 mL over 8 hours (choice C) is within normal limits and does not require immediate reporting. Mild pain at the insertion site (choice D) is common after a chest tube insertion and can be managed with pain medication.
A nurse is assessing a client who has a history of type 2 diabetes mellitus. The nurse should identify which of the following findings as an indication of a microvascular complication?
- A. Peripheral neuropathy
- B. Hypertension
- C. Retinopathy
- D. Stroke
Correct Answer: C
Rationale: The correct answer is C: Retinopathy. In type 2 diabetes, prolonged high blood sugar levels can damage small blood vessels in the retina, leading to retinopathy, a microvascular complication affecting the eyes. This can result in vision problems or even blindness. Peripheral neuropathy (A) is a macrovascular complication affecting the nerves, not the microvasculature. Hypertension (B) is a common comorbidity but not a direct microvascular complication. Stroke (D) is a macrovascular complication involving large blood vessels in the brain, not microvasculature. Thus, the nurse should identify retinopathy (C) as the correct indication of a microvascular complication in a client with type 2 diabetes mellitus.
A nurse is preparing to administer daily medications to a client who is undergoing a procedure at 1000 that requires IV contrast dye. Which of the following routine medications to give at 0800 should the nurse withhold?
- A. Fluticasone
- B. Metoprolol
- C. Metformin
- D. Valproic acid
Correct Answer: C
Rationale: The correct answer is C: Metformin. The nurse should withhold metformin before the procedure with IV contrast dye due to the risk of lactic acidosis. IV contrast dye can affect kidney function, leading to an increased risk of lactic acidosis when combined with metformin. Fluticasone (A), metoprolol (B), and valproic acid (D) are not contraindicated before the procedure with IV contrast dye. Fluticasone is an inhaled corticosteroid, metoprolol is a beta-blocker, and valproic acid is an anticonvulsant. These medications are not typically affected by IV contrast dye and can be safely administered.
A nurse is admitting a client who has meningitis. Which of the following findings should the nurse expect?
- A. Photophobia
- B. Bradycardia
- C. Intermittent headache
- D. Petechiae on the chest
Correct Answer: A
Rationale: The correct answer is A: Photophobia. Photophobia, or sensitivity to light, is a common symptom of meningitis due to inflammation of the meninges surrounding the brain and spinal cord. This occurs because bright light can worsen the headache associated with meningitis. Bradycardia and petechiae on the chest are not typical findings in meningitis. Intermittent headache is vague and not specific to meningitis.