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When assessing a client who has just undergone a cardioversion, the practical nurse (LPN) finds the respirations are 12/minute. Which action should the nurse take first?
- A. Try to vigorously stimulate normal breathing
- B. Ask the RN to assess the vital signs
- C. Measure the pulse oximetry
- D. Continue to monitor respirations
Correct Answer: D
Rationale: Continue to monitor respirations. A rate of 12/minute is acceptable post-cardioversion, requiring no immediate intervention.
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The nurse is caring for a client with heart failure.
- A. Which symptom indicates worsening heart failure in a client?
- B. Weight gain of 2 pounds in 24 hours.
- C. Decreased blood pressure.
- D. Clear lung sounds bilaterally.
- E. Improved exercise tolerance.
Correct Answer: A
Rationale: A weight gain of 2 pounds in 24 hours indicates fluid retention, a sign of worsening heart failure. Decreased blood pressure may occur but is less specific, clear lung sounds suggest stability, and improved exercise tolerance indicates improvement.
The nurse is teaching a client with a new diagnosis of hyperthyroidism about methimazole (Tapazole). Which of the following statements by the client indicates a need for further teaching?
- A. I should report a sore throat to my doctor.
- B. I should take this medication with food.
- C. I should avoid eating iodized salt.
- D. I should stop this medication if I feel better.
Correct Answer: D
Rationale: Stopping methimazole when feeling better is incorrect, as hyperthyroidism requires prolonged treatment to achieve euthyroid status. Options A, B, and C are correct: sore throat may indicate agranulocytosis, food reduces GI upset, and avoiding iodized salt prevents thyroid stimulation.
The nurse is caring for a client with a history of anxiety disorder.
- A. Which intervention is most effective for managing acute anxiety in a client?
- B. Administer a benzodiazepine as ordered.
- C. Encourage deep breathing exercises.
- D. Restrict the client to their room.
- E. Provide a high-stimulus environment.
Correct Answer: B
Rationale: Deep breathing exercises calm the autonomic nervous system, reducing acute anxiety effectively and non-invasively. Benzodiazepines are used cautiously, isolation increases anxiety, and high-stimulus environments worsen it.
The nurse is caring for a client with a history of heart failure who is receiving spironolactone (Aldactone) 25 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I feel tired in the afternoon.
- B. I have a dry mouth.
- C. I have muscle cramps.
- D. I take my medication with food.
Correct Answer: C
Rationale: Muscle cramps suggest hyperkalemia, a serious side effect of spironolactone, a potassium-sparing diuretic, requiring immediate evaluation to prevent arrhythmias. Options A, B, and D are less concerning: fatigue and dry mouth are nonspecific, and taking with food is acceptable.
The client is admitted to the unit with the following lab values. Which of the following lab values should be reported immediately?
- A. BUN $18 \mathrm{mg} / \mathrm{dL}$
- B. $\mathrm{PO}_2 72 \%$
- C. Hemoglobin $10 \mathrm{mg} / \mathrm{dL}$
- D. White blood cell count of 5,500
Correct Answer: B
Rationale: A $\mathrm{PO}_2$ of 72% indicates severe hypoxemia, requiring immediate intervention. BUN, hemoglobin, and WBC values are less urgent.