Nokea
The nurse is assessing a primigravida at 39-weeks gestation during a weekly prenatal visit. Which finding is most important for the nurse to report to the healthcare provider?
- A. Fetal heart rate of 200 beats/minute.
- B. Mild ankle edema.
- C. Complaints of back pain.
- D. Decreased fetal movements.
Correct Answer: A
Rationale: A fetal heart rate of 200 beats per minute is significantly elevated and requires immediate medical attention. This finding could indicate fetal distress, tachycardia, or other serious issues that need prompt evaluation. Mild ankle edema, complaints of back pain, and decreased fetal movements are common in pregnancy but are not as urgent or concerning as a high fetal heart rate.
You may also like to solve these questions
The nurse is caring for a client with a history of myocardial infarction who is experiencing chest pain. Which intervention should the nurse implement first?
- A. Administer oxygen therapy as prescribed.
- B. Obtain an electrocardiogram (ECG).
- C. Administer nitroglycerin sublingually as prescribed.
- D. Administer aspirin as prescribed.
Correct Answer: A
Rationale: Administering oxygen therapy is the priority intervention in managing chest pain in a client with a history of myocardial infarction. Oxygen helps improve oxygenation to the heart muscle, which is crucial in reducing further damage. Obtaining an electrocardiogram (ECG) is important to assess for changes indicative of myocardial infarction, but providing oxygen takes precedence as it directly addresses the physiological need for oxygen. Administering nitroglycerin and aspirin are important interventions but are typically implemented after oxygen therapy to address vasodilation and antiplatelet effects, respectively.
A healthcare provider is assessing a client with a history of hypertension who is currently taking a diuretic. Which assessment finding is most important to report to the healthcare provider?
- A. Potassium level of 3.2 mEq/L
- B. Blood pressure of 148/90 mmHg
- C. Pulse rate of 62 beats per minute
- D. Blood glucose level of 130 mg/dl
Correct Answer: A
Rationale: A potassium level of 3.2 mEq/L is low and places the client at risk for cardiac arrhythmias, requiring immediate intervention. Hypokalemia can result from diuretic use and can lead to serious complications such as irregular heart rhythms. Monitoring and correcting potassium levels are crucial in preventing adverse cardiac events. The other options, though important, do not pose an immediate life-threatening risk compared to the low potassium level.
A client with cirrhosis is admitted with ascites and jaundice. Which assessment finding is most concerning?
- A. Peripheral edema
- B. Confusion and altered mental status
- C. Increased abdominal girth
- D. Yellowing of the skin
Correct Answer: B
Rationale: Confusion and altered mental status are concerning signs of hepatic encephalopathy in a client with cirrhosis. Hepatic encephalopathy is a serious complication of liver disease that requires immediate intervention. Peripheral edema may be present due to fluid accumulation, increased abdominal girth can indicate ascites which is common in cirrhosis, and yellowing of the skin is a typical manifestation of jaundice in liver dysfunction, all of which are important but not as immediately concerning as signs of hepatic encephalopathy.
A client with liver cirrhosis and ascites is admitted with jaundice. Which laboratory value is most concerning to the nurse?
- A. Serum albumin of 3.0 g/dl
- B. Bilirubin of 3.0 mg/dl
- C. Ammonia level of 80 mcg/dl
- D. Prothrombin time of 18 seconds
Correct Answer: C
Rationale: An ammonia level of 80 mcg/dl is elevated and concerning in a client with liver cirrhosis, as it may indicate hepatic encephalopathy. Elevated ammonia levels can lead to neurological symptoms such as confusion, altered mental status, and even coma. Serum albumin, bilirubin, and prothrombin time are important in liver cirrhosis but are not the most concerning for acute neurological deterioration associated with hepatic encephalopathy.
A client with heart failure is prescribed furosemide (Lasix). Which assessment finding should the nurse report to the healthcare provider immediately?
- A. Heart rate of 60 beats per minute
- B. Blood pressure of 100/60 mmHg
- C. Presence of a new murmur
- D. Crackles in the lungs
Correct Answer: D
Rationale: The correct answer is D: Crackles in the lungs. Crackles indicate fluid overload in the lungs, a critical sign in a client with heart failure. This finding suggests that the furosemide may not be effectively managing the fluid balance, and immediate intervention is required. Choices A, B, and C are not immediate concerns in this scenario. A heart rate of 60 beats per minute, a blood pressure of 100/60 mmHg, and the presence of a new murmur are findings that may require monitoring or intervention but are not as urgent as crackles in the lungs in a client with heart failure.