Nokea
A client admitted to the intensive care unit with syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which intervention should the nurse implement first?
- A. Patch one eye.
- B. Reorient often.
- C. Range of motion.
- D. Evaluate swallow
Correct Answer: B
Rationale: Frequent reorientation is crucial for clients with neurological impairments from osmotic demyelination to prevent confusion and assist with orientation. It helps maintain a proper sense of time, place, and person, reducing disorientation. Patching one eye (Choice A) is not a priority intervention for osmotic demyelination and does not address the immediate need for reorientation. Range of motion exercises (Choice C) may be important for overall care, but reorientation takes precedence due to its impact on neurological functioning. Evaluating swallow (Choice D) is not the primary intervention needed for osmotic demyelination; it is essential but not the first priority.
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Following the evacuation of a subdural hematoma, an older adult develops an infection. The client is transferred to the neuro intensive care unit with a temperature of 101.8 F (39.3 C) axillary, pulse of 180 beats/minute, and a blood pressure of 90/60 mmHg. What is the priority intervention to include in this client's plan of care?
- A. Confusion
- B. Check neuro vital signs every 4 hours.
- C. Maintain intravenous access.
- D. Keep the suture line clean and dry.
Correct Answer: C
Rationale: The priority intervention for the client in this scenario is to maintain intravenous (IV) access. Given the client's condition with infection, elevated temperature, tachycardia, and hypotension, it is crucial to ensure IV access for administering antibiotics, fluids, and other medications promptly. This can help manage the infection, stabilize hemodynamics, and support the client's hydration and medication needs. Checking neuro vital signs, although important, is secondary to addressing the immediate need for IV access. Keeping the suture line clean and dry is important for wound care but not the priority when dealing with a systemic infection and hemodynamic instability.
A child with heart failure (HF) is taking digitalis. Which sign indicates to the nurse that the child may be experiencing digitalis toxicity?
- A. Tachycardia
- B. Dyspnea
- C. Vomiting
- D. Muscle cramps
Correct Answer: C
Rationale: Vomiting is a common sign of digitalis toxicity and should be closely monitored. While tachycardia is a common sign of heart failure, it is not typically associated with digitalis toxicity (Choice A). Dyspnea (Choice B) and muscle cramps (Choice D) are not specific signs of digitalis toxicity and can be present in other conditions. Therefore, the presence of vomiting should raise concerns about digitalis toxicity in the child with heart failure.
The nurse is admitting a client from the post-anesthesia unit to the postoperative surgical care unit. Which intervention should the nurse implement first?
- A. Advance to clear liquids as tolerated
- B. Straight catheterization if unable to void
- C. Administer Cefazolin 1 gram IVPQ q6 hours
- D. Obtain a complete blood cell count (CBC) in the morning
Correct Answer: B
Rationale: The correct answer is to perform straight catheterization if the client is unable to void. This action is essential to prevent urinary retention and its potential complications following anesthesia. Option A, advancing to clear liquids, is not the priority upon admission as the focus should be on urinary function first. Option C involves administering an antibiotic, which is important but not the immediate priority. Option D, obtaining a CBC, can be done later and is not as crucial as ensuring proper urinary function postoperatively.
A client with major depression who is taking fluoxetine calls the psychiatric clinic reporting being more agitated, irritable, and anxious than usual. Which intervention should the nurse implement?
- A. Tell the client to have a complete blood count (CBC) drawn
- B. Instruct the client to seek medical attention immediately
- C. Encourage them to take the medication at night with a snack
- D. Explain that these are common side effects of the medication
Correct Answer: B
Rationale: Increased agitation, irritability, and anxiety can be signs of serotonin syndrome or other serious side effects, not common side effects of fluoxetine. Instructing the client to seek medical attention immediately is crucial to address any potential serious adverse reactions. Option A is unnecessary as a CBC would not address the symptoms described. Option C is not the priority when serious side effects are suspected. Option D is incorrect as these symptoms should not be dismissed as common side effects.
A client with multiple sclerosis is receiving baclofen 15 mg PO three times daily. The drug is available in 10 mg tablets. How many tablets should the nurse administer in a 24-hour period? (Enter a numeric value only. If rounding is required, round to the nearest tenth)
- A. 4.5
Correct Answer: A
Rationale: To calculate the total dose of baclofen needed in a 24-hour period, multiply 15 mg by 3 doses, which equals 45 mg. Since the tablets are available in 10 mg strength, divide the total dose needed (45 mg) by the strength of each tablet (10 mg), which equals 4.5 tablets. Rounding off to the nearest tenth, the nurse should administer 4.5 tablets of 10 mg baclofen per day. Therefore, choice A is correct. Choices B, C, and D are irrelevant as they are not provided.