A client who is 24 weeks pregnant presents with a complaint of feeling dizzy when lying on her back. What is the best response by the nurse?

A. Advise the client to lie on her side

B. Encourage the client to drink more fluids

C. Suggest the client elevate her legs when lying down

D. Recommend the client take short walks throughout the day

Correct Answer: A
Rationale: The correct answer is to advise the client to lie on her side. Lying on the side can prevent the compression of the vena cava, which can cause dizziness in pregnant women. Encouraging the client to drink more fluids (Choice B) may be beneficial for other conditions but is not the best response for dizziness when lying on her back. Suggesting the client elevate her legs when lying down (Choice C) is not directly related to the issue described by the client. Recommending the client take short walks throughout the day (Choice D) may be helpful for other pregnancy-related symptoms but is not the most appropriate action for dizziness when lying on her back.

A client is admitted with a diagnosis of diabetic ketoacidosis (DKA). Which laboratory finding is most indicative of this condition?

• A. Serum glucose of 180 mg/dL
• B. Blood pH of 7.30
• C. Positive urine ketones
• D. Serum bicarbonate of 25 mEq/L

Correct Answer: C
Rationale: The correct answer is C: Positive urine ketones. In diabetic ketoacidosis (DKA), the body breaks down fat for energy due to a lack of insulin, leading to ketone production. Positive urine ketones are a hallmark laboratory finding in DKA as they directly reflect the presence of ketosis. Choice A, serum glucose of 180 mg/dL, may be elevated in DKA, but it is not specific to this condition. Choice B, blood pH of 7.30, often shows acidosis in DKA, but urine ketones are more specific to the presence of ketosis. Choice D, serum bicarbonate of 25 mEq/L, would typically be low in DKA due to acidosis rather than elevated.

During a severe asthma exacerbation in a client, what is the nurse's priority?

• A. Administer a rescue inhaler immediately
• B. Prepare for intubation
• C. Encourage deep breathing exercises
• D. Monitor oxygen saturation levels

Correct Answer: A
Rationale: During a severe asthma exacerbation, the nurse's priority is to administer a rescue inhaler immediately. This action helps open the airways and improve breathing, which is crucial in managing the exacerbation. Choice B, preparing for intubation, would be considered if the client's condition deteriorates and they are unable to maintain adequate oxygenation even after using the rescue inhaler. Encouraging deep breathing exercises (Choice C) may not be appropriate during a severe exacerbation as the client may struggle to breathe. While monitoring oxygen saturation levels (Choice D) is important, the immediate administration of a rescue inhaler takes precedence to address the acute breathing difficulty.

After receiving a report, the nurse receives the laboratory values for four clients. Which client requires the nurse’s immediate intervention? The client who is...

• A. Short of breath after a shower and has a hemoglobin of 8 grams
• B. Bleeding from a finger stick and has a prothrombin time of 30 seconds
• C. Febrile and has a WBC count of 14,000/mm3
• D. Trembling and has a glucose level of 50 mg/dL

Correct Answer: D
Rationale: A glucose level of 50 mg/dL is indicative of hypoglycemia, which requires immediate intervention to prevent further complications. Hypoglycemia can lead to serious consequences such as altered mental status, seizures, and even coma if not promptly addressed. The other options do not present immediate life-threatening conditions that require urgent intervention. Shortness of breath with a hemoglobin of 8 grams may indicate anemia but does not require immediate intervention. Bleeding from a finger stick with a prothrombin time of 30 seconds may suggest clotting issues, which are important but not as immediately critical as hypoglycemia. Being febrile with an elevated WBC count could indicate infection, which is concerning but not as urgently critical as hypoglycemia.

What is the most important aspect of colostomy care to teach the client?

• A. Change the colostomy bag only when necessary
• B. Eat a low-residue diet
• C. Assess the stoma for color and swelling
• D. Irrigate the colostomy only if advised by a healthcare provider

Correct Answer: C
Rationale: The most important aspect of colostomy care to teach the client is to assess the stoma for color and swelling. This is crucial as it ensures early detection of complications such as ischemia or infection. Changing the colostomy bag only when necessary is more appropriate than doing it daily, as it prevents unnecessary changes that may irritate the skin. While eating a low-residue diet is beneficial, it is not the most crucial aspect to teach. Irrigating the colostomy should only be done if advised by a healthcare provider, as it is not a routine procedure for all clients with a colostomy.