Recognizing Cues
A nurse is assessing a client admitted with excessive water intake after participating in a marathon. Which findings should the nurse recognize as cues consistent with hyponatremia?
A. Intense thirst, dry mucous membranes, and lethargy
B. Seizures, confusion, and dry mucous membranes
C. Peaked T waves and diarrhea
D. Hypotension, bradycardia, and decreased deep tendon reflexes
Correct Answer: B
Rationale:
Hyponatremia can cause neurologic manifestations such as confusion and seizures due to cerebral edema. Dry mucous membranes may also occur.
A nurse is reviewing assessment findings for a client with end-stage renal disease. Which findings should the nurse analyze as most consistent with hyperkalemia?
A. Flattened T waves, constipation, and muscle cramps
B. Peaked T waves, diarrhea, and recent ACE inhibitor use
C. Hyperactive deep tendon reflexes and positive Chvostek’s sign
D. Hypotension, bradycardia, and decreased deep tendon reflexes
Correct Answer: B
Rationale:
Hyperkalemia is associated with peaked T waves, diarrhea, and risk factors such as ACE inhibitor therapy and ESRD.
A nurse is caring for four clients on a medical-surgical unit. Which client should the nurse assess first?
A. A client with pneumonia reporting fatigue and productive cough
B. A client with a pulmonary embolism who reports sudden chest pain
C. A client with acute bronchitis requesting cough suppressant medication
D. A client with fractured ribs reporting pain rated 7/10
Correct Answer: B
Rationale:
A pulmonary embolism with hypoxemia is life-threatening and requires immediate assessment and intervention due to impaired oxygenation and risk for cardiopulmonary collapse.
A nurse is caring for a client with hyponatremia who develops confusion and seizures. Which intervention should the nurse anticipate implementing?
A. Administer 3% sodium chloride
B. Encourage free water intake every hour
C. Administer spironolactone
D. Restrict sodium-rich foods
Correct Answer: A
Rationale:
Severe symptomatic hyponatremia may require hypertonic saline (3% NaCl) to safely raise serum sodium levels and reduce neurologic complications.
A nurse is evaluating a client receiving treatment for pneumonia. Which finding best indicates that the treatment has been effective?
A. Oxygen saturation increased from 88% to 95% on room air
B. Productive cough remains thick and green
C. Respiratory rate increased from 20/min to 32/min
D. Crackles are now heard throughout all lung fields
Correct Answer: A
Rationale:
Improved oxygen saturation indicates improved gas exchange and lung function following treatment for pneumonia.
A nurse is caring for a client who recently had a stroke and now coughs during meals. Which assessment findings should the nurse identify as cues of aspiration pneumonia?
A. Bradycardia, hypertension, and frothy sputum
B. Fever, coarse crackles, dyspnea, and low oxygen saturation
C. Absent breath sounds and tracheal deviation
D. Inspiratory wheezing relieved by coughing
Correct Answer: B
Rationale:
Aspiration pneumonia commonly occurs when material enters the lungs, leading to inflammation and infection. Manifestations include fever, crackles, dyspnea, tachypnea, and hypoxemia.
A nurse is assessing a client after chest trauma from a motor vehicle collision. Which findings should the nurse analyze as indicating a tension pneumothorax?
A. Bilateral crackles and pink frothy sputum
B. Severe dyspnea, neck vein distention, and absent breath sounds on one side
C. Productive cough with green sputum and fever
D. Bradycardia with dependent edema
Correct Answer: B
Rationale:
Tension pneumothorax causes trapped air to increase intrathoracic pressure, leading to severe respiratory distress, unilateral absent breath sounds, jugular venous distention, and possible tracheal deviation.
A nurse is monitoring a client with a chest tube following chest trauma. Which finding requires immediate intervention?
A. Tidaling noted in the water-seal chamber
B. Drainage of 40 mL during the last hour
C. Sudden absence of tidaling in the chest tube system with increasing dyspnea
D. Mild discomfort at the chest tube insertion site
Correct Answer: C
Rationale:
Sudden cessation of tidaling with respiratory distress may indicate chest tube occlusion and possible tension pneumothorax, which is an emergency.
A nurse is developing a plan of care for a client with dysphagia following a stroke. Which intervention should the nurse include to reduce aspiration risk?
A. Encourage the client to drink liquids through a straw
B. Position the client upright during meals and for 30 minutes afterward
C. Place the client flat immediately after eating
D. Limit coughing during meals to reduce fatigue
Correct Answer: B
Rationale:
Maintaining an upright position helps prevent aspiration of food or liquids into the lungs. Aspiration pneumonia is associated with swallowing dysfunction and impaired airway protection.
A nurse is evaluating a client treated for hyperkalemia. Which finding indicates that treatment has been successful?
A. Presence of peaked T waves on ECG
B. Potassium level decreased from 6.4 mEq/L to 4.3 mEq/L
C. Development of muscle weakness
D. Increased ventricular ectopy noted on telemetry
Correct Answer: B
Rationale:
A potassium level within normal range indicates improvement and decreased risk for cardiac dysrhythmias.
A nurse is assessing a client with sepsis who may be developing disseminated intravascular coagulation (DIC). Which findings should the nurse recognize as concerning cues?
A. Petechiae, bleeding from IV sites, and prolonged bleeding times
B. Hypertension, flushed skin, and bounding pulses
C. Elevated hemoglobin and increased hematocrit
D. Bradycardia and decreased respiratory effort
Correct Answer: A
Rationale:
DIC causes widespread clotting factor consumption, leading to abnormal bleeding manifestations such as petechiae, ecchymosis, oozing from IV sites, and prolonged coagulation times.
A nurse is monitoring a client with septic shock. Which assessment findings should the nurse analyze as cues of developing DIC?
A. Petechiae, bleeding from venipuncture sites, and ecchymosis
B. Elevated blood pressure and bounding pulses
C. Warm flushed skin and bradycardia
D. Increased appetite and polyuria
Correct Answer: A
Rationale:
DIC results in widespread activation of clotting factors followed by excessive bleeding due to factor depletion. Petechiae, oozing blood, and ecchymosis are key cues.
A nurse receives morning laboratory results for four clients. Which client should the nurse assess first?
A. A client with sodium level of 133 mEq/L and mild headache
B. A client with potassium level of 6.5 mEq/L and peaked T waves
C. A client with calcium level of 10.8 mg/dL and constipation
D. A client with magnesium level of 1.5 mg/dL and hyperactive reflexes
Correct Answer: B
Rationale:
Hyperkalemia can cause life-threatening cardiac dysrhythmias. Peaked T waves indicate cardiac conduction abnormalities requiring immediate intervention.
A nurse is caring for a client diagnosed with acute bronchitis who has a persistent productive cough and mild dyspnea on exertion. Which task is appropriate for the nurse to delegate to an assistive personnel (AP)?
A. Assess the client’s lung sounds for wheezing and crackles
B. Teach the client how to use an incentive spirometer
C. Assist the client with oral fluid intake and reinforce coughing exercises
D. Evaluate the effectiveness of prescribed bronchodilator therapy
Correct Answer: C
Rationale:
Assistive personnel can assist with routine, noninvasive tasks such as encouraging fluids and reinforcing previously taught coughing exercises to help mobilize secretions in clients with acute bronchitis.
A nurse is evaluating a client after chest tube placement for pneumothorax. Which finding best indicates that the lung has re-expanded?
A. Continuous bubbling in the water-seal chamber
B. Sudden severe dyspnea
C. Gradual cessation of tidaling in the water-seal chamber
D. Increased subcutaneous emphysema around the insertion site
Correct Answer: C
Rationale:
As the lung re-expands, tidaling gradually decreases and may stop, indicating resolution of the pneumothorax.
A nurse is assessing a client with suspected vitamin B12 deficiency anemia. Which findings should the nurse recognize as cues of macrocytic anemia?
A. Spoon-shaped nails and pica
B. Numbness and tingling of the extremities with glossitis
C. Hematuria and flank pain
D. Severe dehydration and tachycardia
Correct Answer: B
Rationale:
Macrocytic anemia caused by vitamin B12 deficiency commonly presents with neurologic manifestations such as paresthesias along with glossitis and fatigue.
A nurse is assessing a client with iron deficiency anemia. Which findings should the nurse analyze as consistent with microcytic anemia?
A. Glossitis, numbness, and impaired balance
B. Fatigue, pallor, spoon-shaped nails, and pica
C. Petechiae and prolonged bleeding time
D. Fever and neutropenia
Correct Answer: B
Rationale:
Microcytic anemia, especially iron deficiency anemia, commonly presents with fatigue, pallor, koilonychia (spoon nails), and pica.
A nurse is caring for clients on an oncology unit. Which client should the nurse see first?
A. A client with thrombocytopenia reporting bruising on the arms
B. A client with neutropenia who has a temperature of 38.4°C (101.1°F)
C. A client with iron deficiency anemia reporting fatigue
D. A client with macrocytic anemia reporting glossitis
Correct Answer: B
Rationale:
Fever in a neutropenic client may indicate sepsis and requires immediate intervention because the client has limited ability to fight infection.
A nurse discovers that a client’s chest tube has accidentally disconnected from the drainage system. Which action should the nurse take first?
A. Clamp the chest tube near the insertion site
B. Immediately remove the chest tube
C. Place the exposed end of the chest tube into sterile water
D. Turn off wall suction permanently
Correct Answer: C
Rationale:
If a chest tube becomes disconnected, the priority is to reestablish the water-seal system by placing the tube end in sterile water to prevent air from entering the pleural space.
A nurse is evaluating a client receiving treatment for thrombocytopenia. Which finding indicates improvement?
A. Petechiae noted on the lower extremities
B. Platelet count increased from 28,000/mm³ to 110,000/mm³
C. Continued bleeding from venipuncture sites
D. New onset hematuria
Correct Answer: B
Rationale:
An increased platelet count indicates improvement in thrombocytopenia and decreased bleeding risk.
A nurse is reviewing laboratory results for a client receiving chemotherapy. Which finding should the nurse identify as the priority cue indicating neutropenia rather than thrombocytopenia?
A. Platelet count of 40,000/mm³ with petechiae
B. Hemoglobin of 10 g/dL and fatigue
C. Temperature of 38.4°C (101.1°F) with an absolute neutrophil count of 800/mm³
D. Epistaxis and bleeding gums
Correct Answer: C
Rationale:
Neutropenia places the client at high risk for life-threatening infection. Fever in a neutropenic client is a priority finding requiring immediate intervention.
A nurse in a pediatric clinic is assessing a child suspected of having pertussis. Which assessment findings should the nurse analyze as cues consistent with whooping cough?
A. Productive cough with green sputum, crackles, and pleuritic chest pain
B. Barking cough, inspiratory stridor, and hoarseness
C. Uncontrollable coughing spells
D. Sudden onset dyspnea, absent breath sounds, and tracheal deviation
Correct Answer: C
Rationale:
Pertussis (whooping cough) is characterized by severe paroxysmal coughing followed by a forceful inspiratory “whoop.” Vomiting after coughing episodes is also common. Additional findings may include runny nose, watery eyes, and low-grade fever.
A nurse is caring for a client with dysphagia following a stroke. Which action is the priority to reduce the client’s risk for aspiration pneumonia?
A. Encourage the client to drink fluids through a straw
B. Position the client flat during meals to prevent fatigue
C. Keep the head of the bed elevated during and after meals
D. Administer cough suppressant medication before meals
Correct Answer: C
Rationale:
Maintaining the head of the bed elevated helps prevent aspiration by reducing the likelihood of oral contents entering the airway. Aspiration pneumonia is associated with swallowing problems and decreased protective reflexes.
A nurse is caring for a client with thrombocytopenia secondary to chemotherapy. Which intervention should the nurse include in the client’s plan of care?
A. Administer intramuscular injections using a large-bore needle
B. Encourage the client to use a firm-bristled toothbrush twice daily
C. Apply prolonged pressure after venipuncture procedures
D. Place the client on strict neutropenic precautions
Correct Answer: C
Rationale:
Clients with thrombocytopenia are at increased risk for bleeding due to low platelet counts. Applying prolonged pressure after venipuncture helps reduce bleeding risk.
A nurse is evaluating a client receiving anticoagulant therapy for a pulmonary embolism. Which finding best indicates that treatment has been effective?
A. Heart rate decreased from 124/min to 86/min and oxygen saturation improved
B. The client reports worsening pleuritic chest pain
C. The client develops hemoptysis and increasing dyspnea
D. Respiratory rate increased from 18/min to 34/min
Correct Answer: A
Rationale:
Improved oxygenation and stabilization of vital signs indicate improved perfusion and response to therapy for pulmonary embolism.