Nokea
The nurse is talking with a client who is scheduled for cardiac catheterization. Which of the following findings would be essential to follow up? Select all that apply.
- A. elevated serum C-reactive protein level
- B. previous allergic reaction to IV contrast
- C. prolonged PR interval on ECG
- D. received metformin today for type 2 diabetes mellitus
- E. elevated serum creatinine
Correct Answer: B,D,E
Rationale: Allergy to contrast (B), recent metformin use (D), and elevated creatinine (E) increase risks during cardiac catheterization (anaphylaxis, lactic acidosis, and renal injury). CRP (A) and PR interval (C) are less urgent.
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When using an interpreter to teach a client about a procedure to do in the home, the nurse should take which approach?
- A. Speak directly to the interpreter while presenting information and use pauses for questions
- B. Talk to the interpreter in advance and leave the client and interpreter alone
- C. Include a family member and direct communications to that person
- D. Face the client while presenting the information as the interpreter talks in the native language
Correct Answer: D
Rationale: Face the client while presenting the information as the interpreter talks in the native language. This allows non-verbal communication and maintains a client-focused approach.
A client who had a total knee replacement is to be discharged today. Which statement that the client makes indicates a need for further instruction?
- A. When I am walking, I will wear that ugly immobilizer.'
- B. I will sit with my leg elevated.'
- C. I think I understand how to use the continuous passive motion machine.'
- D. I won't put any weight at all on my affected leg.'
Correct Answer: D
Rationale: Total knee replacement typically allows partial weight-bearing with assistance post-surgery; complete non-weight-bearing suggests misunderstanding of mobility instructions.
The morning weight for a client with emphysema indicates that the client has gained 5 pounds in less than a week, even though his oral intake has been modest. The client's weight gain may reflect which associated complication of COPD?
- A. Polycythemia
- B. Cor pulmonale
- C. Left ventricular failure
- D. Compensated acidosis
Correct Answer: B
Rationale: Rapid weight gain in a client with emphysema, despite modest intake, suggests fluid retention, which is commonly associated with cor pulmonale, a complication of COPD involving right heart failure due to lung disease. Answer A (polycythemia) is a blood disorder, not directly linked to weight gain. Answer C (left ventricular failure) is less likely in COPD compared to cor pulmonale. Answer D (compensated acidosis) does not cause weight gain.
Laboratory Reference Ranges
Sodium
136-145 mEq/L
(136-145 mmol/L)
The medical-surgical nurse cares for a group of clients. Which client situations would prompt the nurse to notify the health care provider during the middle of the night? Select all that apply.
- A. Client develops right-sided upper and lower extremity drift
- B. Client found lying unconscious on the floor
- C. Client has order for heparin with surgery planned for the morning
- D. Client has serum sodium of 124 mEq/L (124 mmol/L)
- E. Client refuses a prescribed, routine pain medication
Correct Answer: A,B,C,D
Rationale: Extremity drift (A), unconsciousness (B), heparin before surgery (C), and severe hyponatremia (D) are urgent and require notification. Refusing pain medication (E) is not critical.
An adult is prescribed sulfisoxazole (Gantrisin) for a urinary tract infection. Which comment by the client indicates understanding of the treatment regimen?
- A. When I feel better, I can stop taking the medicine.
- B. I will stay out of the sun when I am taking this drug.
- C. I should restrict fluids during the evening as long as I am on the medicine.
- D. I will bring in a urine specimen every day while I am taking the drug.
Correct Answer: B
Rationale: Sulfisoxazole causes photosensitivity; avoiding sun exposure is critical to prevent skin reactions, indicating understanding.