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The nurse is caring for a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which laboratory value should the nurse monitor closely?
- A. Serum potassium level
- B. Hemoglobin level
- C. White blood cell count
- D. Serum calcium level
Correct Answer: A
Rationale: The correct answer is A: Serum potassium level. When a client with chronic kidney disease (CKD) is receiving erythropoietin therapy, the nurse should closely monitor the serum potassium level. Erythropoietin therapy can stimulate red blood cell production, leading to an increased demand for potassium. This increases the risk of hyperkalemia, making it crucial to monitor potassium levels closely. Choices B, C, and D are incorrect because erythropoietin therapy primarily affects red blood cell production, not hemoglobin, white blood cell count, or serum calcium levels.
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The nurse and an unlicensed assistive personnel (UAP) are providing care for a client with a nasogastric tube (NGT) when the client begins to vomit. How should the nurse manage this situation?
- A. Direct the UAP to measure the emesis while the nurse irrigates the NGT
- B. Stop the NGT feed and notify the healthcare provider
- C. Increase the NGT suction pressure
- D. Elevate the head of the bed
Correct Answer: A
Rationale: During vomiting in a client with an NGT, it is essential for the nurse to direct the UAP to measure the emesis to monitor the output. This helps in assessing the client's condition and response to treatment. Meanwhile, irrigating the NGT can be beneficial to relieve any obstruction that might be contributing to the vomiting. Stopping the NGT feed and notifying the healthcare provider (choice B) is important but not the immediate action needed. Increasing the NGT suction pressure (choice C) is unnecessary and can lead to complications. Elevating the head of the bed (choice D) is a general intervention to prevent aspiration but may not address the immediate issue of managing the vomiting episode and potential tube obstruction.
A client with heart failure is prescribed furosemide (Lasix). Which assessment finding requires immediate intervention?
- A. Heart rate of 60 beats per minute
- B. Blood pressure of 100/60 mmHg
- C. Crackles in the lungs
- D. Presence of a new murmur
Correct Answer: C
Rationale: The correct answer is C. Crackles in the lungs indicate fluid overload, a common issue in heart failure patients. Immediate intervention is necessary to prevent worsening heart failure symptoms and potential complications. A heart rate of 60 beats per minute and a blood pressure of 100/60 mmHg are within normal ranges for many individuals and do not typically require immediate intervention in this context. The presence of a new murmur may be important to monitor but is not the priority when crackles in the lungs suggest fluid overload.
What is the first action the nurse should implement for a client admitted with acute pancreatitis?
- A. Administer intravenous fluids as prescribed
- B. Administer pain medication as prescribed
- C. Place the client on NPO status
- D. Assess the client's abdomen for distention
Correct Answer: C
Rationale: Placing the client on NPO status is the priority action for a client with acute pancreatitis. This step is crucial to rest the pancreas, prevent pancreatic stimulation, and decrease enzyme production. By withholding oral intake, the digestive system is given a chance to rest and recover. Administering intravenous fluids may be necessary but should come after placing the client on NPO status. Pain medication can be administered once the client is stabilized. Assessing the client's abdomen for distention is important but is not the initial priority in managing acute pancreatitis.
During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate first?
- A. Respiratory apnea of 30 seconds
- B. Oxygen saturation rate of 88%
- C. Eight premature ventricular beats every minute
- D. Disconnected monitor signal for the last 6 minutes.
Correct Answer: A
Rationale: The correct answer is A: Respiratory apnea of 30 seconds. Respiratory apnea indicates a cessation of breathing, which is a life-threatening emergency requiring immediate intervention. Priority should be given to assessing and managing airway, breathing, and circulation. Option B, oxygen saturation rate of 88%, can indicate hypoxemia, but addressing the lack of breathing takes precedence. Option C, eight premature ventricular beats every minute, and option D, a disconnected monitor signal, are important but do not pose an immediate threat to the client's life compared to respiratory apnea.
When obtaining a rectal temperature with an electronic thermometer, which action is most important for the nurse to perform?
- A. Hold the thermometer in place.
- B. Place the disposable pad under the buttocks.
- C. Instruct the client to breathe deeply.
- D. Return the probe to the charger.
Correct Answer: A
Rationale: When obtaining a rectal temperature with an electronic thermometer, holding the thermometer in place is crucial. This action ensures accurate temperature measurement and prevents injury to the client. Option B, placing a disposable pad under the buttocks, is not the most important action; it may enhance comfort but does not impact the accuracy of the temperature reading. Option C, instructing the client to breathe deeply, is irrelevant to obtaining a rectal temperature. Option D, returning the probe to the charger, is an incorrect action after temperature measurement.