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The nurse is caring for a client with diabetic ketoacidosis (DKA). Which laboratory value requires immediate intervention?
- A. Serum glucose of 300 mg/dL
- B. Serum potassium of 4.5 mEq/L
- C. Serum bicarbonate of 15 mEq/L
- D. Serum pH of 7.28
Correct Answer: D
Rationale: A serum pH of 7.28 indicates metabolic acidosis in a client with diabetic ketoacidosis (DKA), requiring immediate intervention. In DKA, the body produces excess ketones, leading to acidosis. Monitoring and correcting the pH level is crucial in managing DKA. Serum glucose levels may be high in DKA, but the immediate concern is correcting the acidosis to prevent complications. Serum potassium and bicarbonate levels are also important but not as immediately critical as correcting the acidosis in DKA.
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When assessing a client with left-sided heart failure, which intervention should the nurse implement first?
- A. Administer oxygen therapy as prescribed.
- B. Monitor the client's urine output.
- C. Administer a loop diuretic as prescribed.
- D. Administer morphine as prescribed.
Correct Answer: A
Rationale: Administering oxygen therapy is the initial intervention for a client with left-sided heart failure. This action is crucial in improving oxygen levels and reducing pulmonary congestion. Monitoring urine output is important for assessing renal function in heart failure, but it is not the priority over ensuring adequate oxygenation. Administering loop diuretics helps manage fluid overload but should come after addressing oxygen needs. Morphine may be indicated for pain or anxiety in some cases, but it is not the primary intervention for left-sided heart failure.
The nurse observes an adolescent client preparing to administer a prescribed corticosteroid medication using a metered dose inhaler. What action should the nurse take?
- A. Remind the client to hold their breath after inhaling the medication
- B. Confirm that the client has correctly shaken the inhaler
- C. Affirm that the client has correctly positioned the inhaler
- D. Ask the client if they have a spacer to use for this medication
Correct Answer: A
Rationale: Corrected Rationale: Reminding the client to hold their breath after inhaling the medication is crucial as it helps ensure the medication is absorbed into the lungs. Option B is incorrect because shaking the inhaler is not directly related to the client's inhalation technique. Option C is incorrect as correct positioning of the inhaler is important but not the immediate action needed in this situation. Option D is incorrect as asking about the spacer is not the most relevant action to take at this moment.
A client with heart failure who is on a low sodium diet reports a weight gain of 2 kg in 24 hours. Which intervention should the nurse implement first?
- A. Instruct the client to reduce fluid intake
- B. Monitor the client's intake and output
- C. Administer a diuretic as prescribed
- D. Assess the client for signs of fluid overload
Correct Answer: D
Rationale: The correct first intervention for a client with heart failure who is on a low sodium diet and reports a significant weight gain is to assess the client for signs of fluid overload. This step is crucial in determining the severity of the situation and guiding further treatment. In this scenario, assessing for signs of fluid overload takes priority over other actions such as instructing the client to reduce fluid intake, monitoring intake and output, or administering a diuretic. While these actions may be necessary depending on the assessment findings, the initial priority is to evaluate the client's immediate condition.
The nurse is assessing a client with left-sided heart failure. Which laboratory value is most concerning?
- A. Serum creatinine of 1.5 mg/dL
- B. Serum sodium of 136 mEq/L
- C. Serum potassium of 5.5 mEq/L
- D. Hemoglobin of 12 g/dL
Correct Answer: C
Rationale: A serum potassium level of 5.5 mEq/L is most concerning in a client with left-sided heart failure as it indicates hyperkalemia, requiring immediate intervention. Hyperkalemia can lead to life-threatening cardiac arrhythmias, which can exacerbate heart failure. Serum creatinine of 1.5 mg/dL is slightly elevated but not as immediately concerning as hyperkalemia. Serum sodium of 136 mEq/L is within the normal range. Hemoglobin of 12 g/dL is also within the normal range and not directly related to the client's left-sided heart failure.
The nurse is triaging several children as they present to the emergency room after an accident. Which child requires the most immediate intervention by the nurse?
- A. An 11-year-old with a headache, nausea, and projectile vomiting
- B. A 5-year-old with a broken arm
- C. A 7-year-old with minor abrasions
- D. A 9-year-old with a twisted ankle
Correct Answer: A
Rationale: The correct answer is A. Projectile vomiting in a child with a headache could indicate increased intracranial pressure, requiring immediate attention. Choices B, C, and D do not present with symptoms indicating potentially life-threatening conditions that require urgent intervention.