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A mother brings her child, who has a history of asthma, to the emergency room. The child is wheezing and speaking one word between each breath. The child is anxious, tachycardic, and has labored respirations. Which assessment is most important for the nurse to obtain?
- A. Type of inhaler the child typically uses on a regular basis
- B. Frequency of rescue inhaler use during the week
- C. Last dose and type of rescue inhaler used by the child
- D. Type of allergen exposure or trigger for the current episode
Correct Answer: C
Rationale: The correct answer is C because knowing the last dose and type of rescue inhaler used helps assess if the child has received adequate treatment and if further intervention is needed. This information is crucial in managing an acute asthma exacerbation. Choice A, the type of inhaler the child typically uses, is less critical during an emergency. Choice B, the frequency of rescue inhaler use during the week, is important for general asthma management but does not provide immediate guidance in the acute situation. Choice D, the type of allergen exposure or trigger, is more relevant for preventive strategies and does not directly impact the immediate treatment of the child's acute asthma attack.
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A client complains of paresthesia in the fingers and toes and experiences hand spasms when the blood pressure cuff is inflated. Which serum laboratory finding should the nurse expect to find when assessing the client?
- A. Elevated serum calcium
- B. Low serum magnesium
- C. Low serum calcium
- D. Elevated serum potassium
Correct Answer: C
Rationale: The correct answer is C: Low serum calcium. Hand spasms and paresthesia are indicative of potential hypocalcemia, which is characterized by low serum calcium levels. Elevated serum calcium (Choice A) is not consistent with the symptoms described. Low serum magnesium (Choice B) and elevated serum potassium (Choice D) are not typically associated with hand spasms and paresthesia.
A 9-year-old received a short arm cast for a right radius. To relieve itching under the child's cast, which instructions should the nurse provide to the parents?
- A. Blow cool air from a hair dryer under the cast
- B. Twist the cast back and forth
- C. Shake powder into the cast
- D. Push a pencil under the cast edge
Correct Answer: A
Rationale: Blowing cool air from a hair dryer under the cast is a safe method to relieve itching without damaging the cast or causing injury. The air helps to dry out the moisture that is causing the itching. Twisting the cast back and forth (choice B) can create pressure points and discomfort for the child. Shaking powder into the cast (choice C) can introduce foreign material that may cause skin irritation. Pushing a pencil under the cast edge (choice D) can injure the child's skin or even dislodge the cast.
The nurse is performing a peritoneal dialysis exchange on a client with chronic kidney disease (CKD). Which assessment finding should the nurse report to the healthcare provider?
- A. The appearance of the returning dialysate fluid is cloudy
- B. The client complains of slight shortness of breath during installation
- C. The amount of the returning dialysate fluid is greater than the amount instilled
- D. The client complains of abdominal fullness and cramping during instillation
Correct Answer: A
Rationale: Cloudy dialysate fluid can indicate peritonitis, a serious complication of peritoneal dialysis. Peritonitis is an urgent condition that requires immediate evaluation and treatment. Reporting this finding promptly is crucial to prevent further complications. Choices B, C, and D are not indicative of peritonitis and do not require immediate reporting to the healthcare provider. Complaining of slight shortness of breath, having a greater return volume, and experiencing abdominal fullness and cramping are common occurrences during peritoneal dialysis and do not necessarily indicate an emergent issue.
The client enters the room of a client with Parkinson's disease who is taking carbidopa-levodopa. The client is arising slowly from the chair while the unlicensed assistive personnel (UAP) stands next to the chair. What action should the nurse take?
- A. Demonstrate how to help the client move more efficiently
- B. Offer a PRN analgesic to reduce painful movement
- C. Affirm that the client should arise slowly from the chair
- D. Tell the UAP to assist the client in moving more quickly
Correct Answer: A
Rationale: The correct action for the nurse to take in this situation is to demonstrate how to help the client move more efficiently. As the client is arising slowly from the chair, providing guidance on proper movement techniques can improve the client's mobility and safety. Offering a PRN analgesic (Choice B) is not relevant to the client's situation as there is no indication of pain. Affirming that the client should arise slowly (Choice C) does not address the need for assistance in improving movement efficiency. Instructing the UAP to assist the client in moving more quickly (Choice D) may compromise the client's safety and is not the appropriate action to take.
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.