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The nurse observes a client who begins to exhibit continuous jerking movements, is unable to speak, and is incontinent of urine during the event. Which action is most important for the nurse to take?
- A. Place protective padding between the client and bed rails.
- B. Provide privacy for the client during the event.
- C. Observe the client's behavior during the event.
- D. Record the client's level of consciousness after the event.
Correct Answer: A
Rationale: Padding prevents injury during a seizure, prioritizing client safety over privacy or observation.
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A client recovering from cardiac surgery experiences a dysrhythmia, noted on the telemetry monitor. Which assessment finding is most likely to have contributed to the development of the dysrhythmia?
- A. Calcium level 7.2 mg/dL (1.8 mmol/L).
- B. Potassium level 3.8 mg/dl. (3.8 mmol)
- C. Sodium level 140 mEq/L (140mmol/L).
- D. Oxygen saturation level 97%.
Correct Answer: A
Rationale: Hypocalcemia (low calcium) can cause cardiac dysrhythmias, such as prolonged QT intervals, unlike normal potassium, sodium, or oxygen levels.
A client admitted with thyrotoxicosis is reporting a 'pounding heart in the chest.' Which assessment finding warrants immediate intervention by the nurse?
- A. Anxiety
- B. Hyperglycemia
- C. Fever
- D. Dyspnea.
Correct Answer: D
Rationale: Dyspnea may indicate severe complications like heart failure or thyroid storm, requiring immediate intervention due to potential life-threatening respiratory distress.
The nurse is preparing a teaching plan for a client taking a prescribed diuretic for edema in the lower extremities. Which instruction should the nurse include in this teaching plan?
- A. Take the diuretic every day, regardless of weight loss or muscle weakness.
- B. Weigh yourself daily at the same time and report excessive weight loss.
- C. Limit fluid intake while taking the diuretic to reduce fluid retention.
- D. Stop taking the medication when the edema in the lower extremities subsides.
Correct Answer: B
Rationale: Daily weight monitoring helps evaluate diuretic effectiveness and detect complications. Continuous diuretic use despite weakness, limiting fluids, or stopping medication without consultation can lead to adverse outcomes.
While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?
- A. Neutrophil count.
- B. C-reactive protein level.
- C. Platelet count.
- D. Serum potassium and sodium levels.
Correct Answer: B
Rationale: C-reactive protein (CRP) is a sensitive marker of inflammation, which often accompanies worsening wound size. Neutrophils indicate acute infection, platelets relate to clotting, and electrolytes are not directly related to wound healing.
A client is scheduled for a scleral buckling procedure after previously having multiple laser coagulation procedures done for retinal tears. Which Information about the immediate postoperative period should the nurse provide this client?
- A. Report reoccurring visual signs of retinal detachment.
- B. Maintain the head in one postoperative position.
- C. Watch for signs of infection in the surgical eye.
- D. Ambulate to the bathroom with assistance.
Correct Answer: A
Rationale: Reporting signs of retinal detachment is critical to ensure the success of the scleral buckling procedure.