A postoperative client with a history of diabetes mellitus is showing signs of hyperglycemia. What should the nurse assess first?

Correct Answer: C

Rationale: In the context of a postoperative client with a history of diabetes mellitus showing signs of hyperglycemia, the nurse should assess the client's capillary blood glucose level first (Option C). This is crucial because hyperglycemia can lead to serious complications such as diabetic ketoacidosis or hyperosmolar hyperglycemic state, which require immediate intervention. Monitoring the blood glucose level helps in determining the severity of hyperglycemia and guides appropriate treatment. Assessing for signs of infection (Option A) is important in a postoperative client, but hyperglycemia needs immediate attention to prevent complications specific to diabetes. Monitoring fluid intake and output (Option B) is essential for overall assessment but does not directly address the priority of managing hyperglycemia. Assessing serum potassium level (Option D) is important, but correcting hyperglycemia takes precedence to prevent electrolyte imbalances associated with uncontrolled diabetes. In an educational context, understanding the priority assessment in a client with diabetes experiencing postoperative hyperglycemia is crucial for nurses to provide timely and effective care. This scenario highlights the significance of prioritizing assessments based on the client's condition and the potential risks associated with uncontrolled hyperglycemia.

Correct Answer: B

Rationale: The correct answer is B) Check the client's blood pressure for signs of hypotension. In the context of a client with a recent myocardial infarction prescribed a beta-blocker, monitoring for hypotension is crucial because beta-blockers can cause a decrease in blood pressure. This is a common side effect of beta-blockers due to their mechanism of action in blocking the effects of adrenaline on the heart. Hypotension can lead to decreased perfusion to vital organs and exacerbate cardiac issues. Option A) Monitor the client for bradycardia is incorrect because while beta-blockers can slow the heart rate, bradycardia is not the primary side effect to monitor for in this scenario. Option C) Monitor the client for signs of hyperglycemia is incorrect because beta-blockers are more likely to cause hypoglycemia rather than hyperglycemia. Option D) Monitor for signs of fluid retention is incorrect because beta-blockers are not typically associated with fluid retention; in fact, they are often used to manage conditions like heart failure where fluid retention is a concern. Understanding the common side effects of medications and their implications in specific clinical contexts is essential for nurses to provide safe and effective care to their patients, especially those with cardiac conditions like myocardial infarction. Regular monitoring and assessment help in early identification and management of potential complications.

Correct Answer: B

Rationale: A neurological assessment is the priority when a stroke is suspected to determine the extent of brain injury and identify any immediate risks, such as impaired airway, speech deficits, or loss of motor function. Early recognition of these signs is essential for timely intervention and to guide further treatment like the administration of tPA, if appropriate.

Correct Answer: B

Rationale: Before administering nitroglycerin, which can lower blood pressure and heart rate, it is important to assess both to avoid exacerbating hypotension or bradycardia. Nitroglycerin helps relieve chest pain by dilating coronary arteries, but its vasodilating effect can also cause a significant drop in blood pressure, which can be dangerous for some clients.

Correct Answer: B

Rationale: In this scenario, the nurse's priority action should be option B: Monitor the client's potassium levels. This is the correct choice because furosemide is a loop diuretic that can cause potassium depletion, leading to muscle weakness. By monitoring the client's potassium levels, the nurse can assess for hypokalemia and take appropriate actions to prevent complications. Option A, administering potassium supplements, seems like a viable choice; however, it should not be the initial action. Potassium supplements should only be given based on laboratory results and under healthcare provider's orders to avoid the risk of hyperkalemia. Option C, instructing the client to increase their salt intake, is incorrect. Heart failure clients are typically advised to limit salt intake to reduce fluid retention and workload on the heart. Option D, discontinuing the furosemide, is not the priority action as abruptly stopping diuretic therapy can lead to fluid overload and exacerbation of heart failure symptoms. Educationally, understanding the rationale behind monitoring potassium levels in heart failure clients on diuretics is crucial for nurses to provide safe and effective care, preventing potential complications associated with electrolyte imbalances. Monitoring potassium levels allows for timely interventions and promotes client safety and well-being.