In preparing to administer a scheduled dose of intravenous furosemide (Lasix) to a client with heart failure, the nurse notes that the client's B-Type Naturetic peptide (BNP) is elevated. What action should the nurse take?

Correct Answer: C

Rationale: The correct action is to administer the dose of furosemide as scheduled (Choice C) because an elevated BNP level indicates increased fluid volume and pressure in the heart. Furosemide is a diuretic that helps reduce fluid overload in heart failure patients, which can alleviate symptoms and improve cardiac function. Holding the dose (Choice D) could delay necessary treatment, potentially worsening the patient's condition. Measuring oxygen saturation (Choice A) is important but not the immediate priority in this situation. Administering nitroglycerin (Choice B) is not appropriate as it is used for chest pain related to angina, not for treating elevated BNP levels in heart failure.

Correct Answer: C

Rationale: The correct answer is C: Presence of uremic frost. HHNS is characterized by severe hyperglycemia leading to osmotic diuresis and dehydration, not uremia. A: Increased heart rate is a non-specific sign of stress. B: Visual disturbances can be seen in diabetic retinopathy but are not specific to HHNS. D: Decreased mentation is common in HHNS due to severe dehydration and hyperglycemia leading to altered mental status.

Correct Answer: D

Rationale: The correct answer is D: Maintain skeletal pin sites and assess for signs of infection. This is important to prevent complications like infection, which can be severe. The nurse should regularly assess the pin sites for redness, swelling, or discharge. This intervention ensures early detection and prompt treatment of any signs of infection, reducing the risk of serious complications. Choice A is incorrect because performing passive range of motion to the right leg may disrupt the traction and interfere with the healing process. Choice B is incorrect because removing skeletal weights every shift can lead to loss of traction, compromising the fracture alignment and healing process. Choice C is incorrect because turning the client frequently from prone to supine positions may also disrupt the traction and increase the risk of complications.

Correct Answer: D

Rationale: The correct answer is D because it demonstrates empathy and acknowledges the client's feelings without admitting fault. By saying "I understand you are frustrated with the wait time," the nurse validates the client's emotions and shows a willingness to listen and address concerns. This response can help de-escalate the situation and build rapport. Choice A is incorrect because it doesn't directly address the client's emotions. Choice B is incorrect as it prioritizes the client based on their anger rather than medical need. Choice C is incorrect as it may come off as dismissive of the client's feelings and lacks empathy.

Correct Answer: A

Rationale: The correct answer is A because raising the side rails and placing the call bell within reach ensures the safety and immediate accessibility of the client, which is the highest priority in nursing care. This intervention helps prevent falls or other accidents and allows the client to call for assistance if needed. Choice B is incorrect because teaching pushing techniques is important but not the highest priority at this moment. Choice C, timing and recording uterine contractions, is also important but not the highest priority compared to ensuring the client's safety. Choice D, positioning for anesthesia distribution, is relevant but not as critical as ensuring immediate access to assistance in case of emergency.