Nokea
Which assessment finding should indicate to the nurse that a client with arterial hypertension is experiencing a cardiac complication?
- A. Complaints of an occipital headache
- B. A palpable dorsal pedis pulse bilaterally
- C. Complaints of shortness of breath on exertion
- D. A blood pressure of 160/90
Correct Answer: C
Rationale: The correct answer is C, complaints of shortness of breath on exertion. This symptom is indicative of heart failure, a common cardiac complication of arterial hypertension. Shortness of breath on exertion is often due to the heart's inability to pump effectively, leading to fluid buildup in the lungs. Choices A, B, and D are incorrect because complaints of an occipital headache, a palpable dorsal pedis pulse bilaterally, and a blood pressure of 160/90 do not specifically indicate a cardiac complication in a client with arterial hypertension.
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The nurse is caring for a client who has a chest tube in place following a pneumothorax. The nurse notes that there is continuous bubbling in the water seal chamber of the chest tube drainage system. What action should the nurse take?
- A. Check for kinks in the tubing
- B. Notify the healthcare provider
- C. Replace the chest tube drainage system
- D. Reinforce the chest tube dressing
Correct Answer: B
Rationale: The correct action for the nurse to take when observing continuous bubbling in the water seal chamber of the chest tube drainage system is to notify the healthcare provider. Continuous bubbling indicates a possible air leak, and the healthcare provider needs to be informed to assess the situation and take appropriate actions. Checking for kinks in the tubing (Choice A) may be done initially but is not the priority when continuous bubbling is present. Replacing the chest tube drainage system (Choice C) and reinforcing the chest tube dressing (Choice D) are not immediate actions needed in response to continuous bubbling in the water seal chamber.
Which assessment finding is most indicative of deep vein thrombosis (DVT) in a client's right leg?
- A. Dorsiflexes the right foot and left on command
- B. A 3 by 5 cm ecchymosis area covering the right calf
- C. Right calf is 3 cm larger in circumference than the left
- D. Bilateral lower extremity has 3+ pitting edema
Correct Answer: C
Rationale: The correct answer is C because a significant increase in the circumference of the right calf compared to the left calf is a classic sign of deep vein thrombosis (DVT). Option A is incorrect as dorsiflexing the right foot and left on command does not specifically indicate DVT. Option B describes an ecchymosis area which is more indicative of a bruise rather than DVT. Option D suggests bilateral lower extremity edema, which is not specific to DVT and can be seen in various conditions such as heart failure or renal issues.
A client who had an intraosseous (IO) cannula placed by the healthcare provider for emergent fluid resuscitation is complaining of severe pain and numbness below the IO site. The skin around the site is pale and edematous. What action should the nurse take first?
- A. Discontinue the IO infusion
- B. Administer an analgesic via the IO site
- C. Elevate the extremity with the IO site
- D. Notify the healthcare provider
Correct Answer: A
Rationale: In this scenario, the client's symptoms of severe pain, numbness, pale skin, and edema below the IO site raise concerns for complications like compartment syndrome or extravasation. The priority action for the nurse is to discontinue the IO infusion to prevent further harm to the client. Administering an analgesic via the IO site or elevating the extremity with the IO site may delay addressing the potential serious complications. While notifying the healthcare provider is important, the immediate action to ensure client safety is to stop the infusion.
A client who is taking ciprofloxacin (Cipro) reports to the nurse of having a loss of appetite and a metallic taste in the mouth. What action should the nurse implement?
- A. Reassure the client that these are common side effects of ciprofloxacin.
- B. Instruct the client to take ciprofloxacin with food.
- C. Notify the healthcare provider of the client's symptoms.
- D. Encourage the client to increase fluid intake.
Correct Answer: C
Rationale: The correct action for the nurse to take when a client on ciprofloxacin reports loss of appetite and a metallic taste in the mouth is to notify the healthcare provider of the client's symptoms. These symptoms could indicate a need for a change in medication or additional treatment, which the healthcare provider would need to assess. Instructing the client to take ciprofloxacin with food (choice B) may help with gastrointestinal upset but will not address the reported symptoms. Reassuring the client (choice A) is important for providing emotional support but does not address the need for further evaluation. Encouraging increased fluid intake (choice D) is generally beneficial but may not directly address the specific side effects reported.
A 24-year-old female client who has a history of rheumatoid arthritis (RA) is taking ibuprofen (Motrin) for pain relief. Which information should the nurse provide the client about taking this medication?
- A. Take the medication with meals
- B. Take the medication with an antacid
- C. Report any changes in stool color to your healthcare provider
- D. Avoid taking aspirin while using this medication
Correct Answer: C
Rationale: The correct answer is to instruct the client to report any changes in stool color to the healthcare provider. This is important because changes in stool color can indicate gastrointestinal bleeding, a serious side effect of nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen. Choice A is incorrect because while taking ibuprofen with meals can help reduce stomach upset, it is not the most crucial information to provide. Choice B is incorrect as taking ibuprofen with an antacid is not a standard recommendation. Choice D is also incorrect because while ibuprofen and aspirin are both NSAIDs, they can be taken together under certain circumstances, but it's important to be cautious and follow healthcare provider recommendations.