Nokea
The nurse is assessing a client with left-sided heart failure. Which assessment finding requires immediate intervention?
- A. Jugular venous distention
- B. Shortness of breath
- C. Crackles in the lungs
- D. Peripheral edema
Correct Answer: C
Rationale: In a client with left-sided heart failure, crackles in the lungs are a critical assessment finding that necessitates immediate intervention. Crackles indicate pulmonary congestion, a sign of worsening heart failure that requires prompt attention to prevent respiratory distress. Jugular venous distention, shortness of breath, and peripheral edema are also common in heart failure, but crackles specifically point to pulmonary involvement and the urgent need for intervention.
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The nurse is caring for a client with a chest tube in place following a pneumothorax. Which finding requires immediate intervention?
- A. Oxygen saturation of 95%
- B. Crepitus around the insertion site
- C. Subcutaneous emphysema
- D. Drainage of 50 ml per hour
Correct Answer: C
Rationale: Subcutaneous emphysema requires immediate intervention in a client with a chest tube following a pneumothorax as it can indicate a pneumothorax recurrence or air leak. Oxygen saturation of 95% is within the normal range and does not require immediate intervention. Crepitus around the insertion site can be expected post-procedure and may not necessitate immediate action. Drainage of 50 ml per hour is a normal finding and does not raise immediate concerns.
A client who had a gestational trophoblastic disease (GTD) evacuated 2 days ago is being... What intervention is most important for the nurse to implement?
- A. Teach the client about the use of a home pregnancy test.
- B. Schedule weekly home visits to draw hCG values.
- C. Schedule a 5-week follow-up with the healthcare provider.
- D. Begin chemotherapy administration during the first home visit.
Correct Answer: B
Rationale: The most important intervention for the nurse to implement is to schedule weekly home visits to draw hCG values. Monitoring hCG levels is crucial in detecting potential complications like choriocarcinoma following GTD evacuation. Teaching about home pregnancy tests (Choice A) may not be as immediate and critical as monitoring hCG levels. A 5-week follow-up appointment (Choice C) may be too delayed for close monitoring. Initiating chemotherapy (Choice D) without appropriate hCG monitoring and evaluation is not recommended as the first-line intervention.
An adult female client with chronic kidney disease (CKD) asks the nurse if she can continue taking over-the-counter medications. Which medication provides the greatest threat to this client?
- A. Magnesium hydroxide (Maalox).
- B. Birth control pills.
- C. Cough syrup containing codeine.
- D. Cold medication containing alcohol.
Correct Answer: A
Rationale: The correct answer is A: Magnesium hydroxide (Maalox). In clients with CKD, magnesium can accumulate to toxic levels due to decreased excretion by the kidneys. Therefore, it poses the greatest threat to this client population. Choice B, birth control pills, is not typically contraindicated in CKD. Choice C, cough syrup containing codeine, may require dose adjustments but is not the greatest threat. Choice D, cold medication containing alcohol, is a concern mainly in liver disease, not CKD.
To reduce the risk of being named in a malpractice lawsuit, which action is most important for the nurse to take?
- A. Adhere consistently to standards of care.
- B. Thoroughly document all client interactions.
- C. Build a good rapport with clients.
- D. Work closely with the healthcare team.
Correct Answer: A
Rationale: Adhering consistently to standards of care is crucial for nurses to reduce the risk of being named in a malpractice lawsuit. Following established protocols and guidelines ensures that the care provided is safe and effective. Thoroughly documenting all client interactions is also essential to support the care provided and to have a record of the interventions. Building a good rapport with clients is important for communication and trust but does not directly reduce the risk of malpractice. Working closely with the healthcare team is valuable for collaboration but might not directly impact the risk of malpractice unless it relates to following standards of care.
A client presents at the clinic with blepharitis. What instructions should the nurse provide for home care?
- A. Use bilateral eye patches while sleeping to prevent injury to the eyes.
- B. Wear sunglasses when outdoors to prevent photophobia.
- C. Apply cold compresses to reduce inflammation.
- D. Apply warm moist compresses then gently scrub eyelids with diluted baby shampoo.
Correct Answer: D
Rationale: The correct answer is D. Blepharitis is managed with warm moist compresses to help loosen debris and oils on the eyelids, followed by gentle scrubbing with a mild solution like diluted baby shampoo. This helps in controlling the condition. Choice A is incorrect as using eye patches while sleeping is not a standard recommendation for blepharitis. Choice B is incorrect as wearing sunglasses does not directly treat blepharitis but may help with light sensitivity. Choice C is incorrect as cold compresses are not typically used for blepharitis, as warm compresses are more effective in managing the condition.