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The nurse is caring for a client with a history of heart failure who is receiving lisinopril (Prinivil) 10 mg PO daily. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Potassium 5.5 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 5.5 mEq/L) is a serious complication of lisinopril, an ACE inhibitor, 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 nurse is caring for a client who is postoperative day 1 after a total shoulder replacement. Which of the following actions should the nurse prioritize?
- A. Encourage use of a sling
- B. Administer pain medication as needed
- C. Keep the affected arm in adduction
- D. Monitor the surgical dressing for drainage
Correct Answer: A
Rationale: Using a sling maintains shoulder immobilization, preventing dislocation post-replacement. Options B, C, and D are secondary: pain management is routine, adduction is incorrect, and dressing monitoring is less urgent.
The nurse is caring for a 10 year-old child who has just been diagnosed with diabetes insipidus. The parents ask about the treatment prescribed, vasopressin. What is priority in teaching the child and family about this drug?
- A. The child should carry a nasal spray for emergency use
- B. The family must observe the child for dehydration
- C. Parents should administer the daily intramuscular injections
- D. The client needs to take daily injections in the short-term
Correct Answer: A
Rationale: Diabetes insipidus results from reduced secretion of the antidiuretic hormone, vasopressin. The child will need to administer daily injections of vasopressin, and should have the nasal spray form of the medication readily available. A medical alert tag should be worn.
After admission for elective surgery, an adult says to the nurse, 'They asked me if I had advance directives. I don't even know what that is.' What is the best response by the nurse?
- A. Advance directives are usually written by persons who have a terminal illness. They are not indicated for elective surgery.
- B. An advance directive is a document that tells the medical and nursing staff what your wishes are regarding certain health care items should you not be able to make decisions for yourself.
- C. An advance directive includes information about you and your specific medical history that could be important to care givers if you are not alert.
- D. Advance directives direct your family about your plans for distributing your belongings when you are no longer here.
Correct Answer: B
Rationale: Advance directives specify healthcare preferences for incapacitation, relevant for any adult, clearly explaining their purpose.
The nurse is aware that the effect of antihypertensive drug therapy may be affected by a 75 year-old client's
- A. poor nutritional status
- B. decreased gastrointestinal motility
- C. increased splanchnic blood flow
- D. altered peripheral resistance
Correct Answer: B
Rationale: Decreased gastrointestinal motility, together with shrinkage of the gastric mucosa and changes in hydrochloric acid levels, will decrease absorption of medications and interfere with their actions.
The nurse is caring for a client with a history of chronic lymphocytic leukemia.
- A. Which symptom should the nurse report immediately for a client with chronic lymphocytic leukemia?
- B. Fatigue and weakness.
- C. Enlarged, painless lymph nodes.
- D. Fever and night sweats.
- E. A hemoglobin of 9.0 g/dL.
Correct Answer: C
Rationale: Fever and night sweats may indicate infection or disease progression in chronic lymphocytic leukemia, requiring immediate evaluation. Fatigue, lymph node enlargement, and low hemoglobin are expected.