the nurse assesses distended neck veins in a client sitting in a chair to eat what intervention is the nurses priority
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Nursing Elites

ATI RN

Endocrinology Exam

1. The nurse assesses distended neck veins in a client sitting in a chair to eat. What intervention is the nurse's priority?

Correct answer: C

Rationale: The correct answer is to assess the pulse and blood pressure. Distended neck veins can indicate fluid volume overload or heart failure, which can lead to hemodynamic instability. Assessing the pulse and blood pressure will provide immediate information on the client's cardiovascular status. Documenting the observation in the chart (choice A) is important but not the priority when immediate assessment is needed. Measuring urine specific gravity and volume (choice B) is important for assessing renal function but is not the priority in this situation. Assessing the client's deep tendon reflexes (choice D) is not relevant to addressing distended neck veins in a client sitting to eat.

2. The healthcare professional is assessing a client with hypertension. Which client outcome is indicative of effective hypertension management?

Correct answer: C

Rationale: The correct answer is 'No indication of renal impairment.' Effective hypertension management aims to prevent complications such as renal impairment. Checking for signs of kidney issues, like abnormal renal function tests, is crucial in monitoring the client's condition. Choices A, B, and D are not specific indicators of effective hypertension management. Pedal edema, sexual dysfunction, and a single blood pressure reading are important but do not solely determine the effectiveness of managing hypertension.

3. A client is receiving an IV infusion of an antibiotic. The client calls the nurse feeling uneasy due to congestion. Which action by the nurse is most appropriate?

Correct answer: B

Rationale: In this situation, the client's symptoms of congestion and feeling uneasy may indicate an anaphylactic reaction, which can be life-threatening. The most appropriate action is to call the Rapid Response Team to provide immediate assistance and interventions. Elevating the head of the bed, administering diphenhydramine, or slowing the IV infusion rate are not the priority actions in the case of a potential severe allergic reaction. These interventions may delay necessary emergency care and potentially worsen the client's condition.

4. A client is hospitalized with a urinary tract infection (UTI). Which clinical manifestation alerts the nurse to the possibility of a complication from the UTI?

Correct answer: C

Rationale: Fever and chills are systemic symptoms that may indicate a more severe infection or a complication of a urinary tract infection (UTI). While burning on urination and cloudy, dark urine are common symptoms of UTI, fever and chills suggest a more serious condition requiring immediate attention. Hematuria, which is blood in the urine, is also a concerning symptom but is more indicative of inflammation or infection rather than a complication.

5. The nurse teaches a client who is newly diagnosed with coronary artery disease. Which instruction does the nurse include to minimize complications of this disease?

Correct answer: C

Rationale: The correct answer is to advise the client to talk to their provider about medications to help quit smoking. Smoking is a major risk factor for coronary artery disease, and quitting smoking can significantly reduce the risk of complications. Choice A is incorrect because exercise is beneficial for managing coronary artery disease, but should be started gradually and under guidance. Choice B is incorrect and inappropriate as it undermines the client's ability to take control of their health. Choice D is incorrect because while a balanced diet is important, specifically targeting carbohydrates alone may not be the most effective or healthy approach for managing coronary artery disease.

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