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The nurse is caring for a client who is receiving IV fluids at 150 mL/hour. Which of the following findings indicates fluid overload?
- A. Blood pressure of 120/80 mmHg.
- B. Heart rate of 80 bpm.
- C. Crackles in the lung bases.
- D. Urine output of 50 mL/hour.
Correct Answer: C
Rationale: Crackles in the lung bases suggest pulmonary edema from fluid overload. Options A, B, and D are normal findings.
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A client has recently been diagnosed with Type 1 diabetes mellitus. The nurse is instructing the client about self-administering insulin. What should be included in the teaching? Select all that apply.
- A. Pinch the muscle and inject the needle at a 45-degree angle.
- B. Shake the vial of insulin before drawing it up.
- C. When using the abdominal site, inject at least 1 inch from the umbilicus.
- D. When mixing insulins, draw up the regular insulin before the NPH.
- E. Do a finger stick glucose test before administering insulin.
- F. Use one site per day for insulin injections.
Correct Answer: C,D,E
Rationale: Injecting 1 inch from the umbilicus ensures absorption, drawing regular insulin before NPH prevents contamination, and checking glucose confirms dosing need. Pinch skin (not muscle), don't shake insulin, and rotate sites.
A woman who was recently diagnosed with multiple myeloma says to the nurse, 'Why did this happen to me? I've always been a good person. What did I do to deserve this?' What should the nurse do initially?
- A. Remind the client that she is not dying now and has some time left
- B. Call the chaplain to discuss why it happened to her
- C. Respond by recognizing how difficult this situation must be
- D. Tell her she didn't do anything to deserve it
Correct Answer: C
Rationale: Acknowledging the client's emotional distress validates her feelings, fostering therapeutic communication. Other responses dismiss or redirect her concerns.
The nurse is caring for a client with a history of heart failure who is receiving spironolactone (Aldactone) 25 mg PO daily. Which of the following laboratory results should the nurse report immediately?
- A. Potassium 5.8 mEq/L.
- B. Sodium 138 mEq/L.
- C. Creatinine 1.2 mg/dL.
- D. Calcium 9.0 mg/dL.
Correct Answer: A
Rationale: Hyperkalemia (5.8 mEq/L) is a serious spironolactone side effect, risking arrhythmias. Options B, C, and D are normal.
The nurse is caring for a client with a history of HIV/AIDS.
- A. Which laboratory finding is most concerning for a client with HIV/AIDS?
- B. CD4 count of 150 cells/mm³.
- C. Viral load of 10,000 copies/mL.
- D. White blood cell count of 5,000/mm³.
- E. Hemoglobin of 12.0 g/dL.
Correct Answer: A
Rationale: A CD4 count of 150 cells/mm³ indicates severe immunosuppression in HIV/AIDS, increasing infection risk and requiring immediate intervention. High viral load is concerning but less urgent, and normal WBC and hemoglobin are unremarkable.
An 80 year-old nursing home resident has a temperature of 101.6 degrees Fahrenheit rectally. This is a sudden change in an otherwise healthy client. Which should the nurse assess first?
- A. Lung sounds
- B. Urine output
- C. Level of alertness
- D. Appetite
Correct Answer: C
Rationale: Level of alertness. Assessing the level of consciousness (alert vs. lethargic vs. unresponsive) will help the provider determine the severity of the acute episode. If the client is alert, responses to questions about complaints can be followed-up quickly.