Nokea
The nurse is providing care for a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which assessment finding requires immediate intervention?
- A. Serum sodium of 140 mEq/L.
- B. Serum osmolality of 280 mOsm/kg.
- C. Weight gain of 2 pounds in 24 hours.
- D. Serum sodium of 130 mEq/L.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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When assessing the health of a community, what is the most important information for the nurse to obtain?
- A. life expectancy of clients in the community
- B. mortality rates in the community
- C. description of health problems by community leaders
- D. expressed needs of community members
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
During a follow-up visit, a client with hypertension reports that they often forget to take their medication. What should the nurse do first?
- A. educate the client on the importance of medication adherence
- B. explore the reasons for the client's forgetfulness
- C. provide the client with a pill organizer
- D. adjust the client's medication schedule
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The healthcare provider is preparing to administer digoxin (Lanoxin) to a client. Which assessment finding should the healthcare provider report before administering the medication?
- A. Apical pulse of 58 beats per minute.
- B. Serum potassium level of 3.0 mEq/L.
- C. Blood pressure of 140/90 mm Hg.
- D. Client reports seeing halos around lights.
Correct Answer: D
Rationale: Seeing halos around lights is a classic symptom of digoxin toxicity, known as visual disturbances. This finding indicates an adverse effect of digoxin and should be reported immediately to the healthcare provider. Monitoring for visual changes is crucial as it can progress to more severe toxicity, leading to life-threatening dysrhythmias or other complications. Apical pulse, serum potassium level, and blood pressure are important assessments when administering digoxin, but the presence of visual disturbances, such as seeing halos around lights, takes precedence due to its direct association with digoxin toxicity. Changes in these other parameters should also be noted and addressed, but they are not the priority when compared to a symptom directly linked to potential toxicity.
During a home visit, the nurse finds that an elderly client has multiple expired medications. What should the nurse do first?
- A. instruct the client to dispose of the expired medications
- B. review the client's current medication regimen
- C. contact the client's healthcare provider
- D. educate the client on the dangers of taking expired medications
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
During a 2 wk postoperative follow-up home visit, a female client who had gastric bypass surgery exhibits bad tenderness, shoulder pain, & describes feelings of malaise. Her vital signs are: T 101.8, BP 100/50, HR 104, and RR 18. Which action should the RN take?
- A. have the client transported via ambulance to the hospital
- B. recheck the client's vital signs in 30 minutes
- C. instruct the client to drive to the hospital for admission
- D. determine the client's current symptoms
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.