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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 would be of GREATest concern to the nurse?
- 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 (potassium 5.8 mEq/L) is a serious complication of spironolactone, a potassium-sparing diuretic, risking arrhythmias in heart failure. Options B, C, and D are normal: sodium 138 mEq/L, creatinine 1.2 mg/dL, and calcium 9.0 mg/dL do not indicate complications.
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The home care nurse has been managing a client for 6 weeks. What is the best method to determine the quality of care provided by a home health care aide assigned to assist with the care of this client?
- A. Ask the client and family if they are satisfied with the care given
- B. Determine the home health aide is care to a consistent with the plan of care
- C. Investigate if the home health aide is prompt and stays an appropriate length of time for care
- D. Check the documentation of the aide for appropriateness and comprehensiveness
Correct Answer: B
Rationale: Although the nurse must complete all of the above responsibilities, evaluation of an adherence to the plan of care is the first priority. The plan of care is based on the reason for referral, provider's orders, the initial nursing assessment, the client's responses to the planned interventions, and the client's and family's feedback or inquiries.
Which of the following findings distinguishes a hydrocele from an inguinal hernia?
- A. The swelling cannot be reduced and is translucent.
- B. The swelling cannot be reduced and is opaque.
- C. The swelling can be reduced and is translucent.
- D. The swelling can be reduced and is opaque.
Correct Answer: A
Rationale: A hydrocele is non-reducible, translucent swelling due to fluid around the testis, unlike an inguinal hernia, which is often reducible and opaque.
The nurse is receiving reports about four pregnant women in active labor who have been admitted to the labor and delivery unit. Which of the following women should the nurse see FIRST?
- A. A 27-year-old nullipara at 38-weeks gestation, has a cervical dilatation of $2 \mathrm{~cm}$, fetus in transverse lie with baseline FHT of $155 \mathrm{bpm}$.
- B. A 32-year-old multipara at term, cervical dilatation of $8 \mathrm{~cm}$, fetus in a vertex presentation with the presenting part at +2 station.
- C. A 22-year-old nullipara at term, cervical dilatation of $10 \mathrm{~cm}, 100 \%$ effaced, fetus presenting as left occiput posterior with short-term variability of the FHT at 3-5 beats.
- D. A 34-year-old multipara at 37-weeks gestation, has intact amniotic membranes, cervical dilatation of $3 \mathrm{~cm}$, and fetus in a frank breech presentation with the presenting part at 0 station.
Correct Answer: B
Rationale: The multipara at 8 cm dilatation is in advanced labor and likely to deliver soon, making her the priority. Options A, C, and D are less urgent: transverse lie needs monitoring, nullipara at 10 cm has a longer second stage, and breech at 3 cm is early.
A newly diagnosed diabetic is learning to administer her injections of NPH and regular insulin. Which statement indicates that the client understands the nurse's teaching regarding proper insulin administration?
- A. I will administer the NPH and regular insulin in two separate injections.
- B. I will withdraw the dose of regular insulin before withdrawing the NPH insulin.
- C. It does not matter which insulin is withdrawn first as long as the amount is correct.
- D. I will withdraw the dose of NPH insulin before withdrawing the regular insulin.
Correct Answer: B
Rationale: When mixing NPH and regular insulin, regular insulin (clear) should be withdrawn first to avoid contaminating it with NPH (cloudy). Separate injections are not standard. Order matters (C is incorrect). Withdrawing NPH first risks contamination.
A child with epiglottitis.
Which of the following nursing observations would indicate to the nurse that a child with epiglottitis is having an early complication of hypoxemia?
- A. Heart rate of 148 beats per minute.
- B. Bluish discoloration of the skin.
- C. Bluish discoloration around the mouth.
- D. Difficulty swallowing.
Correct Answer: A
Rationale: Strategy: Determine how each answer choice relates to epiglottitis. (1) correct-heart rate correlates with hypoxemia and is an early finding, along with restlessness (2) cyanosis, late sign (3) circumoral cyanosis, late sign (4) sign of epiglottitis