Nokea
A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?
- A. Blood pressure
- B. Heart rate
- C. Urine output
- D. Respiratory rate
Correct Answer: B
Rationale: The correct answer is B: Heart rate. A decrease in heart rate indicates adequate fluid replacement in a burn-injured patient due to improved cardiac output and perfusion. When fluid resuscitation is effective, the heart doesn't need to work as hard to maintain circulation. Blood pressure (choice A) may fluctuate initially but is not a reliable indicator of fluid replacement alone. Urine output (choice C) is important but may take time to stabilize. Respiratory rate (choice D) may be affected by pain or stress, not solely fluid status. Other choices are not relevant.
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A nurse is caring for a client who has a postoperative ileus and an NG tube that has drained 2,500 mL in the past 6 hr. Which of the following electrolyte imbalances should the nurse monitor the client for?
- A. Decreased potassium level
- B. Increased sodium level
- C. Increased calcium level
- D. Decreased magnesium level
Correct Answer: A
Rationale: The correct answer is A: Decreased potassium level. Postoperative ileus can lead to gastrointestinal fluid losses, causing a decrease in potassium levels due to excessive drainage through the NG tube. Potassium is an important electrolyte for maintaining normal muscle function, including the heart. Monitoring potassium levels is essential to prevent complications such as cardiac arrhythmias.
Incorrect choices:
B: Increased sodium level - Unlikely in this scenario as excessive drainage would lead to fluid and electrolyte loss.
C: Increased calcium level - Unrelated to postoperative ileus and NG tube drainage.
D: Decreased magnesium level - Possible but not as critical as monitoring potassium levels in this situation.
A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority?
- A. Hemoglobin of 12 g/dL
- B. Platelet count of 350,000/mm3
- C. CD4-T-cell count 180 cells/mm3
- D. White blood cell count of 10,000/mm3
Correct Answer: C
Rationale: The correct answer is C: CD4-T-cell count 180 cells/mm3. In HIV care, monitoring the CD4-T-cell count is crucial as it reflects the immune system's ability to fight infections. A low CD4 count indicates a weakened immune system, increasing the client's susceptibility to opportunistic infections. This value guides treatment decisions, such as initiating antiretroviral therapy. The other options, while important, do not directly reflect the client's immune status in the context of HIV. Hemoglobin and platelet counts are relevant for assessing anemia and clotting function, respectively. White blood cell count is a general indicator of infection or inflammation. Prioritizing CD4-T-cell count ensures appropriate management of HIV and prevention of complications.
A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications?
- A. Encourage the use of an incentive spirometer
- B. Administer oxygen therapy
- C. Provide early ambulation
- D. Monitor for chest pain
Correct Answer: A
Rationale: The correct answer is A: Encourage the use of an incentive spirometer. This intervention helps prevent pulmonary complications postoperatively by promoting deep breathing, improving lung expansion, and preventing atelectasis. Incentive spirometry helps the client maintain lung function and prevent respiratory complications such as pneumonia. Administering oxygen therapy (B) is important but not as effective in preventing complications as using an incentive spirometer. Early ambulation (C) is beneficial for circulation but does not directly prevent pulmonary complications. Monitoring for chest pain (D) is essential for assessing cardiac issues but does not specifically address pulmonary complications.
A nurse is caring for a client who is experiencing menopausal symptoms and asks the nurse about menopausal hormone therapy (HT). The nurse should inform the client that HT is not recommended due to which of the following findings in the client's medical history?
- A. History of breast cancer
- B. History of hypertension
- C. History of diabetes
- D. History of osteoarthritis
Correct Answer: A
Rationale: The correct answer is A: History of breast cancer. Menopausal hormone therapy (HT) is contraindicated in women with a history of breast cancer due to the potential risk of hormone-dependent cancer recurrence. Hormones can stimulate the growth of estrogen-sensitive breast cancer cells, increasing the risk of cancer recurrence. Therefore, it is crucial for the nurse to inform the client with a history of breast cancer that HT is not recommended. Choices B, C, and D are not directly contraindications for HT in menopausal clients, as long as these conditions are well-controlled and monitored.
A nurse is reviewing laboratory values for a client who has systemic lupus erythematosus (SLE). Which of the following values should give the nurse the best indication of the client's renal function?
- A. Serum creatinine
- B. Serum potassium
- C. White blood cell count
- D. Hemoglobin level
Correct Answer: A
Rationale: The correct answer is A: Serum creatinine. Creatinine is a waste product produced by muscles and filtered out by the kidneys. In clients with SLE, renal involvement is common. Elevated serum creatinine levels indicate impaired renal function, as the kidneys are not effectively filtering out waste products. Monitoring serum creatinine levels helps assess renal function and detect kidney damage early.
Choices B, C, D, and E are incorrect as they do not directly reflect renal function. Serum potassium levels (B) are more indicative of electrolyte balance, white blood cell count (C) indicates immune response, and hemoglobin level (D) reflects oxygen-carrying capacity.