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A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg, a fluid intake of 960 mL, and an output of 300 mL in the past 12 hr. Which of the following actions should the nurse take?
- A. Lower the head of the bed to semi-Fowler's.
- B. Administer prescribed corticosteroids.
- C. Slow infusion rate and contact the provider.
- D. Change infusion to lactated Ringer's and maintain rate.
Correct Answer: C
Rationale: Correct Answer: C - Slow infusion rate and contact the provider.
Rationale: The client is showing signs of fluid volume overload with dyspnea, elevated blood pressure, and a significant fluid intake-output discrepancy. Slowing the infusion rate will help reduce fluid intake and potentially prevent worsening of the overload. Contacting the provider is crucial for further assessment and possible adjustment of the treatment plan.
Summary:
A: Lowering the head of the bed may help with respiratory distress but does not address the underlying issue of fluid overload.
B: Administering corticosteroids is not indicated for fluid overload and may worsen the situation.
D: Changing to lactated Ringer's does not address the immediate need to slow down the infusion rate and seek provider guidance.
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A nurse is planning care for a client who has a lump in their right breast. Which of the following findings increases the client's risk of developing breast cancer?
- A. Daily caffeine consumption
- B. A history of seasonal allergies
- C. Oral contraceptives were taken for the last 6 years
- D. Routine use of multivitamins
Correct Answer: C
Rationale: The correct answer is C. Oral contraceptives have been associated with an increased risk of breast cancer due to the hormonal changes they induce in the body. Estrogen and progesterone in oral contraceptives can promote the growth of breast cells, potentially leading to cancer. Daily caffeine consumption (A) and a history of seasonal allergies (B) are not directly linked to breast cancer development. Routine use of multivitamins (D) is generally considered beneficial for overall health and does not increase breast cancer risk.
A nurse is caring for a client who had a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care?
- A. Encourage the client to ambulate independently.
- B. Turn the client by log rolling with a turning sheet.
- C. Position the client in a high Fowler’s position.
- D. Apply a heating pad to the lower back.
Correct Answer: B
Rationale: The correct answer is B: Turn the client by log rolling with a turning sheet. After a lumbar laminectomy, it is essential to prevent twisting or bending at the waist to avoid damaging the surgical site. Log rolling with a turning sheet maintains proper alignment of the spine. Encouraging independent ambulation (A) may put strain on the surgical area. Positioning in a high Fowler's position (C) may increase pressure on the surgical site. Applying a heating pad (D) can lead to increased inflammation and potential burns.
A nurse is caring for a client who is experiencing diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse?
- A. Check potassium levels.
- B. Begin bicarbonate continuous IV infusion.
- C. Initiate a continuous IV insulin infusion.
- D. Administer 0.9% sodium chloride.
Correct Answer: D
Rationale: The correct answer is D: Administer 0.9% sodium chloride. The priority intervention in DKA is fluid resuscitation to correct dehydration and electrolyte imbalances. 0.9% sodium chloride helps restore intravascular volume and improves kidney perfusion. Checking potassium levels (A) is important but can wait until after fluid resuscitation. Beginning bicarbonate infusion (B) is not recommended as it can worsen acidosis. Initiating continuous IV insulin infusion (C) is important but should follow fluid resuscitation. Administering 0.9% sodium chloride takes precedence in managing DKA.
A nurse is providing teaching to a client who has a new prescription for warfarin. Which of the following medications should the nurse instruct the client to avoid? (Select all that apply)
- A. Ferrous sulfate
- B. Echinacea
- C. Aspirin
- D. Dextromethorphan
- E. Naproxen
Correct Answer: C, E
Rationale: The correct choices are C (Aspirin) and E (Naproxen) because they both increase the risk of bleeding when used with warfarin, an anticoagulant. Aspirin and Naproxen are nonsteroidal anti-inflammatory drugs (NSAIDs) that can further inhibit platelet function and prolong bleeding time, leading to potential complications. Ferrous sulfate (A) is an iron supplement and does not directly interact with warfarin. Echinacea (B) is an herbal supplement with minimal known interactions with warfarin. Dextromethorphan (D) is a cough suppressant and does not impact warfarin's anticoagulant effects. In summary, the nurse should instruct the client to avoid Aspirin and Naproxen to prevent potential bleeding complications when taking warfarin.
A nurse is caring for a client who is postoperative and develops respiratory depression after receiving morphine for pain control. Which of the following medications should the nurse expect the provider to prescribe?
- A. Flumazenil
- B. Calcium gluconate
- C. Diphenhydramine
- D. Naloxone
Correct Answer: D
Rationale: The correct answer is D: Naloxone. Naloxone is an opioid antagonist that reverses the effects of opioids, including respiratory depression. Therefore, the nurse should expect the provider to prescribe naloxone to counteract the respiratory depression caused by morphine. Flumazenil (A) is a benzodiazepine antagonist and would not be effective in this situation. Calcium gluconate (B) is used to treat calcium deficiencies and would not address respiratory depression. Diphenhydramine (C) is an antihistamine and not indicated for reversing opioid-induced respiratory depression.