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Which problem in a client requires the most immediate intervention by the nurse?
- A. Finger paresthesias related to carpal tunnel syndrome.
- B. Increasing sharp pain related to compartment syndrome.
- C. Increasing burning pain related to a Morton's neuroma.
- D. Increasing sharp pain related to plantar fasciitis.
Correct Answer: B
Rationale: The correct answer is B. Compartment syndrome is a medical emergency that can lead to tissue damage and loss of limb function. Immediate intervention is crucial to prevent further complications. Finger paresthesias related to carpal tunnel syndrome (A) are not life-threatening and can be managed conservatively. Morton's neuroma (C) and plantar fasciitis (D) are painful conditions, but they do not pose an immediate threat to the client's health or limb function.
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A client with type 1 diabetes mellitus is experiencing nausea and vomiting. What advice should the nurse give regarding insulin administration?
- A. Skip your insulin dose until you can eat.'
- B. Take your insulin as prescribed, but monitor your blood glucose closely.'
- C. Reduce your insulin dose by half.'
- D. Only take your long-acting insulin.'
Correct Answer: B
Rationale: The correct answer is B because skipping insulin can lead to dangerous complications like diabetic ketoacidosis. Taking insulin as prescribed ensures blood glucose control, preventing hyperglycemia. Monitoring blood glucose closely helps adjust doses accordingly. Choice A is incorrect as skipping insulin can be life-threatening. Choice C is incorrect as reducing insulin without proper monitoring can lead to unstable glucose levels. Choice D is incorrect as both long-acting and short-acting insulin are essential for managing type 1 diabetes.
A patient with systemic lupus erythematosus (SLE) is prescribed hydroxychloroquine. What is the most important instruction the nurse should give?
- A. Report any vision changes immediately.
- B. Take the medication with milk.
- C. Avoid high-fat foods.
- D. Increase intake of green leafy vegetables.
Correct Answer: A
Rationale: The correct answer is A: Report any vision changes immediately. This is crucial because hydroxychloroquine can cause retinal toxicity, which may lead to irreversible vision loss. Monitoring for vision changes allows for early detection and intervention. Choice B is incorrect as hydroxychloroquine is typically taken with food or milk to reduce gastrointestinal side effects. Choice C is irrelevant as there is no specific dietary restriction for hydroxychloroquine. Choice D is also incorrect as there is no evidence to support increasing green leafy vegetable intake in relation to hydroxychloroquine therapy.
The patient has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan?
- A. Maintain the patient on bed rest.
- B. Auscultate lung sounds every 4 hours.
- C. Monitor for Trousseau's and Chvostek's signs.
- D. Encourage fluid intake up to 4000 mL every day.
Correct Answer: D
Rationale: The correct answer is D: Encourage fluid intake up to 4000 mL every day. High calcium levels can lead to dehydration, so encouraging fluid intake helps prevent this complication. Increased fluid intake also promotes calcium excretion through urine. Bed rest (A) is not directly related to managing high calcium levels. Auscultating lung sounds (B) every 4 hours is more relevant for respiratory issues. Monitoring for Trousseau's and Chvostek's signs (C) is associated with low calcium levels, not high levels.
What instruction should a patient with a history of hypertension be provided when being discharged with a prescription for a thiazide diuretic?
- A. Avoid foods high in potassium.
- B. Take the medication at bedtime.
- C. Monitor weight daily.
- D. Limit fluid intake to 1 liter per day.
Correct Answer: C
Rationale: Rationale:
C is correct because thiazide diuretics can cause fluid retention, leading to weight gain, which may indicate worsening heart failure or hypertension. Daily weight monitoring helps detect fluid retention early, enabling timely intervention.
Summary:
A: Incorrect. Thiazide diuretics can cause potassium loss, so avoiding potassium-rich foods is not necessary.
B: Incorrect. Taking the medication in the morning is preferred to prevent nocturia and sleep disturbances.
D: Incorrect. Fluid intake should not be limited unless advised by a healthcare provider to prevent dehydration.
A patient with chronic obstructive pulmonary disease (COPD) is experiencing severe dyspnea. What position should the nurse encourage the patient to assume?
- A. Supine
- B. Prone
- C. High Fowler's
- D. Trendelenburg
Correct Answer: C
Rationale: The correct answer is C: High Fowler's. This position helps improve lung expansion and breathing efficiency by maximizing chest expansion. Sitting upright reduces pressure on the diaphragm, allowing for better ventilation. Supine (A) position can worsen dyspnea by restricting lung expansion. Prone (B) position is not ideal for COPD patients as it can hinder breathing. Trendelenburg (D) position, where the patient's feet are elevated above the head, can increase pressure on the diaphragm and impair breathing, making it inappropriate for a patient experiencing severe dyspnea.