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Which of these findings should the nurse report immediately after a client has a liver biopsy?
- A. Temperature of 99.5 degrees F (37.5 degrees C)
- B. Blood pressure of 108/70
- C. Pulse oximetry reading of 96%
- D. Severe abdominal pain
Correct Answer: D
Rationale: The correct answer is D, severe abdominal pain. After a liver biopsy, severe abdominal pain is a critical finding that requires immediate reporting as it may indicate internal bleeding or damage to the liver. The other vital signs provided in choices A, B, and C are within normal limits and may not be directly related to complications post liver biopsy. Therefore, the priority is to address the severe abdominal pain promptly to prevent any further complications.
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A client with hypertension has been prescribed a calcium channel blocker. What should the nurse include in the client's teaching plan?
- A. Monitor heart rate regularly
- B. Avoid potassium-rich foods
- C. Increase fluid intake to avoid dehydration
- D. Take the medication with food
Correct Answer: A
Rationale: Corrected Rationale: Calcium channel blockers can cause bradycardia, so it is important for the client to monitor their heart rate regularly. This helps detect any significant changes in heart rate that may require medical attention. Choice B is incorrect because there is no need to avoid potassium-rich foods with calcium channel blockers. Choice C is incorrect as increasing fluid intake is not specifically related to calcium channel blockers. Choice D is incorrect as calcium channel blockers are usually taken with or without food, depending on the specific medication, but not specifically on an empty stomach.
The nurse administers an antibiotic for a respiratory tract infection. To evaluate the medication's effectiveness, which laboratory values should the nurse monitor?
- A. Platelet count and red blood cell count.
- B. White blood cell count and sputum culture.
- C. Hemoglobin A1c and glucose tolerance test.
- D. Arterial blood gases and serum electrolytes.
Correct Answer: B
Rationale: The correct answer is B: White blood cell count and sputum culture. Monitoring white blood cell count and sputum cultures is essential to assess the effectiveness of the antibiotic in treating the respiratory tract infection. Changes in white blood cell count can indicate the body's response to infection, while sputum cultures help determine if the antibiotic is targeting the specific pathogens causing the infection. Choices A, C, and D are incorrect because platelet count, red blood cell count, hemoglobin A1c, glucose tolerance test, arterial blood gases, and serum electrolytes are not directly related to evaluating the effectiveness of an antibiotic in treating a respiratory tract infection.
What pathophysiological events occur sequentially in the development of atherosclerosis?
- A. Foam cells release growth factors.
- B. Smooth muscle grows over fatty streaks creating fibrous plaques.
- C. Macrophages consume low-density lipoprotein (LDL) and create foam cells.
- D. Arterial endothelium injury causes inflammation.
Correct Answer: D
Rationale: The correct sequence of pathophysiological events in the development of atherosclerosis starts with arterial endothelium injury causing inflammation. This inflammation triggers the formation of foam cells by macrophages consuming low-density lipoprotein (LDL). Subsequently, smooth muscle grows over fatty streaks, creating fibrous plaques. Therefore, option D is the correct answer. Choices A, B, and C are incorrect because they do not reflect the accurate chronological order of events in the pathogenesis of atherosclerosis.
A client with myasthenia gravis (MG) is receiving immunosuppressive therapy. Recent lab tests show decreased serum magnesium. What nursing action is most important?
- A. Observe rhythm on telemetry monitor.
- B. Check for visual difficulties.
- C. Assess for hip and hand joint pain.
- D. Note the most recent hemoglobin level.
Correct Answer: A
Rationale: Magnesium plays a crucial role in maintaining normal cardiac rhythms, particularly in patients with cardiac conditions. Abnormal levels can lead to arrhythmias, which is why continuous monitoring of the heart's electrical activity is important. Magnesium's effect on neuromuscular and cardiac function makes it essential to monitor its levels, and any discrepancies can impact treatment decisions. Checking for visual difficulties (choice B) may be important in MG but is not the priority in the context of decreased serum magnesium. Assessing for hip and hand joint pain (choice C) is not directly related to the issue of decreased serum magnesium. Noting the most recent hemoglobin level (choice D) is not the priority in this situation compared to monitoring the cardiac rhythm due to low magnesium levels.
A client with Parkinson's disease is prescribed levodopa/carbidopa. The nurse instructs the client to take the medication with meals. Which rationale should the nurse provide for taking the medication with food?
- A. It enhances the effectiveness of the medication
- B. It helps to improve absorption
- C. It prevents orthostatic hypotension
- D. It reduces gastrointestinal upset
Correct Answer: D
Rationale: The correct answer is D: 'It reduces gastrointestinal upset.' Levodopa/carbidopa can cause nausea and other gastrointestinal side effects. Taking the medication with food can help reduce these side effects and improve the client's comfort. Choices A, B, and C are incorrect because taking the medication with food does not primarily enhance effectiveness, improve absorption, or prevent orthostatic hypotension. The main reason for advising to take the medication with meals is to minimize gastrointestinal upset.