A healthcare professional is assessing a client with severe dehydration. Which finding indicates a need for immediate intervention?

Correct Answer: C

Rationale: The correct answer is C: Urine output of 20 ml/hour. In severe dehydration, decreased urine output indicates compromised renal function and impaired fluid balance, necessitating immediate intervention to prevent further complications. A: Heart rate of 110 bpm is elevated but not an immediate concern. B: Blood pressure of 90/60 mm Hg is low but may be compensated in dehydration. D: Dry mucous membranes are a sign of dehydration but not an immediate threat compared to inadequate urine output.

Correct Answer: A

Rationale: The correct answer is A: Blood urea nitrogen (BUN). BUN is a waste product that reflects protein intake and kidney function. In chronic kidney disease, high protein intake can increase BUN levels, so monitoring BUN helps assess the effectiveness of the low-protein diet. Incorrect choices: B: Serum potassium - This is more related to kidney function but not specifically affected by a low-protein diet. C: Serum calcium - Calcium levels are not directly affected by protein intake or a low-protein diet in chronic kidney disease. D: Creatinine clearance - This measures kidney function but is not directly influenced by protein intake.

Correct Answer: C

Rationale: The correct answer is C: Evaluate the client's physical health status. This is crucial during detoxification as substance withdrawal can lead to serious physical health complications such as seizures or cardiac issues. Assessing physical health status allows for prompt intervention if needed. Obtaining a detailed substance use history (A) can provide valuable information but is not immediate priority during initial assessment. Establishing a trusting nurse-client relationship (B) is important but ensuring physical safety comes first. Determining client's readiness for change (D) is important for long-term treatment planning but not as urgent as assessing physical health status.

Correct Answer: B

Rationale: The correct answer is B: Lowered cholesterol levels. Atorvastatin is a statin medication used to lower cholesterol levels, reducing the risk of further cardiovascular events in patients with a history of MI. Lowering cholesterol helps prevent plaque buildup in arteries, reducing the likelihood of another MI. Increased blood pressure (A) and decreased heart rate (C) are not direct indicators of atorvastatin's effectiveness. Improved liver function (D) may be a consideration due to potential side effects, but the primary goal of atorvastatin is to lower cholesterol levels to prevent cardiovascular events.

Correct Answer: D

Rationale: The correct answer is D: Hyperglycemia. Risperidone is an atypical antipsychotic medication known to cause metabolic side effects such as hyperglycemia. The nurse should monitor the client for signs and symptoms of high blood sugar levels, such as increased thirst, frequent urination, and fatigue. Hypertension (choice A) is not a common side effect of risperidone. Weight loss (choice B) is less likely as risperidone is associated with weight gain. Hyperactivity (choice C) is not a typical side effect of risperidone. Therefore, monitoring for hyperglycemia is essential in clients taking risperidone.

Correct Answer: B

Rationale: The correct answer is B: Encourage passive range-of-motion exercises. This intervention helps improve joint mobility, reduce stiffness, and alleviate pain in clients with rheumatoid arthritis. Passive range-of-motion exercises can prevent joint contractures and maintain joint function. Applying cold packs (A) may help reduce inflammation but does not address joint stiffness. Administering a muscle relaxant (C) is not typically indicated for rheumatoid arthritis. Providing a high-calorie diet (D) is important for overall health but does not directly address joint pain and stiffness in this case.

Correct Answer: C

Rationale: The correct answer is C: Take the medication on an empty stomach. Levothyroxine should be taken on an empty stomach in the morning, at least 30 minutes before eating, to ensure optimal absorption. Food can interfere with the absorption of levothyroxine, reducing its effectiveness. Taking it with a meal (option A) or at bedtime (option B) may lead to decreased absorption. Taking it with an antacid (option D) can also interfere with absorption. Therefore, the best instruction is to take the medication on an empty stomach to maximize its therapeutic effects.

Correct Answer: C

Rationale: The correct answer is C: Clear lung sounds. Clear lung sounds indicate effective treatment as they suggest improved air exchange and resolution of lung congestion caused by pneumonia. Increased respiratory rate (A) and decreased oxygen saturation (B) are signs of respiratory distress and ineffective treatment. Elevated white blood cell count (D) indicates ongoing infection, not effectiveness of treatment. Therefore, clear lung sounds are the best indicator of treatment effectiveness in bacterial pneumonia.

Correct Answer: C

Rationale: The correct instruction is C: Use this medication twice daily for long-term control. Salmeterol is a long-acting beta-agonist used for maintenance therapy in asthma to provide long-term control of symptoms and prevent exacerbations. It should not be used for acute asthma attacks as it does not provide quick relief like rescue inhalers such as albuterol (choice A). It is not meant to replace albuterol, so it should not be used before using albuterol (choice B). Using salmeterol as needed for wheezing (choice D) is not appropriate as it is a maintenance medication and not a rescue medication.