Nokea
The nurse is evaluating the health status of an older client. Which finding is most important for the nurse to report to the healthcare provider?
- A. Client reports decreased urine output
- B. Client reports loss of appetite
- C. Client reports pain in the lower back
- D. Client reports a persistent cough
Correct Answer: C
Rationale: The correct answer is C because pain in the lower back may indicate a potential serious issue such as kidney problems or infection in the elderly. The kidneys are located in the lower back region, so pain in this area could be a sign of kidney dysfunction. The nurse should report this finding to the healthcare provider immediately for further evaluation and intervention.
Choice A is incorrect because decreased urine output can be a common issue in older adults and may not always indicate a serious problem. Choice B is incorrect as loss of appetite can have various causes and may not be as urgent as lower back pain. Choice D is also incorrect as a persistent cough can have multiple causes, but it is not as concerning as potential kidney issues indicated by lower back pain in an older client.
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Which instruction should the nurse provide to an elderly client who is taking an ACE inhibitor and a calcium channel blocker?
- A. Wear long-sleeved clothing when outdoors
- B. Report the onset of sore throat
- C. Eat plenty of potassium-rich food
- D. Change the position slowly
Correct Answer: D
Rationale: The correct answer is D: Change the position slowly. Elderly clients taking both ACE inhibitors and calcium channel blockers are at risk for orthostatic hypotension. Instructing them to change positions slowly helps prevent sudden drops in blood pressure and dizziness upon standing up.
A: Wearing long-sleeved clothing when outdoors is not directly related to the medications mentioned.
B: Reporting the onset of a sore throat is important for monitoring potential side effects of medications but not specific to the combination of ACE inhibitors and calcium channel blockers.
C: Eating plenty of potassium-rich foods is not typically contraindicated for clients taking ACE inhibitors and calcium channel blockers, but it is not the most essential instruction compared to preventing orthostatic hypotension.
In summary, changing position slowly is crucial to prevent orthostatic hypotension, which is a common side effect of these medications in elderly clients.
The nurse is caring for a client who is receiving heparin therapy. Which laboratory value should the nurse monitor to determine the effectiveness of the therapy?
- A. Prothrombin time (PT)
- B. Partial thromboplastin time (PTT)
- C. International normalized ratio (INR)
- D. Activated partial thromboplastin time (aPTT)
Correct Answer: C
Rationale: Rationale:
1. Heparin primarily affects the intrinsic pathway of coagulation.
2. International Normalized Ratio (INR) is used to monitor the effectiveness of anticoagulation therapy.
3. INR is more specific for monitoring heparin therapy compared to other options.
4. Prothrombin Time (PT) and Activated Partial Thromboplastin Time (aPTT) are not as accurate for heparin monitoring.
5. Partial Thromboplastin Time (PTT) is used to monitor heparin therapy, but INR is a more precise indicator of heparin's effect.
In preparing to administer a scheduled dose of intravenous furosemide (Lasix) to a client with heart failure, the nurse notes that the client's B-Type Naturetic peptide (BNP) is elevated. What action should the nurse take?
- A. Measure the client's oxygen saturation before taking further action
- B. Administer a PRN dose of nitroglycerin (Nitrostat)
- C. Administer the dose of furosemide as scheduled
- D. Hold the dose of furosemide until contacting the healthcare provider
Correct Answer: C
Rationale: The correct action is to administer the dose of furosemide as scheduled (Choice C) because an elevated BNP level indicates increased fluid volume and pressure in the heart. Furosemide is a diuretic that helps reduce fluid overload in heart failure patients, which can alleviate symptoms and improve cardiac function. Holding the dose (Choice D) could delay necessary treatment, potentially worsening the patient's condition. Measuring oxygen saturation (Choice A) is important but not the immediate priority in this situation. Administering nitroglycerin (Choice B) is not appropriate as it is used for chest pain related to angina, not for treating elevated BNP levels in heart failure.
While assessing a client who is experiencing Cheyne-Stokes respirations, the nurse observes periods of apnea. What action should the nurse implement?
- A. Elevate the head of the client's bed
- B. Auscultate the client's breath sounds
- C. Measure the length of the apneic periods
- D. Suction the client's oropharynx
Correct Answer: C
Rationale: The correct answer is C: Measure the length of the apneic periods. This action is crucial in assessing the severity of Cheyne-Stokes respirations and guiding further interventions. By measuring the length of apneic periods, the nurse can determine the duration of respiratory pauses and their impact on oxygenation. This information helps in deciding the appropriate treatment, such as administering supplemental oxygen or notifying the healthcare provider. Elevating the head of the bed (choice A) can help with breathing but does not address the root cause. Auscultating breath sounds (choice B) is important but does not directly address the apneic periods. Suctioning the oropharynx (choice D) is not indicated unless there is an airway obstruction.
A client is taught how to collect a 24-hour urine specimen. Which statement indicates understanding of the procedure?
- A. I should keep the urine specimen refrigerated.
- B. I need to start the collection in the morning after my first void.
- C. I will collect the urine for 24 hours and keep it on ice.
- D. I will start collecting the urine after discarding my first morning specimen.
Correct Answer: D
Rationale: The correct answer is D because discarding the first morning specimen ensures accurate collection starts. Choice A is incorrect because refrigeration is unnecessary for a 24-hour urine collection. Choice B is incorrect as the first void should be included. Choice C is incorrect as there's no need to keep the urine on ice.