Nokea
A 50-year-old female is in the hospital with peripheral artery disease. In the nursing care plan, the nurse lists the following nursing diagnosis: Ineffective tissue perfusion: peripheral related to venous stasis. Which of the following would not be an appropriate nursing action to list in the implementation of this diagnosis?
- A. Keep the client's extremities cold
- B. Check for strength and symmetry of peripheral pulses
- C. Keep the client's legs elevated
- D. Monitor for any constrictions, such as clothes or covers that are too tight around the legs
Correct Answer: A
Rationale: Keeping the client's extremities cold would worsen perfusion issues and is not recommended. In peripheral artery disease, maintaining warmth is crucial to promote vasodilation and improve blood flow. Checking peripheral pulses for strength and symmetry, keeping the client's legs elevated to reduce venous stasis, and monitoring for constrictions that may impair circulation are appropriate nursing actions to enhance tissue perfusion in this case. Thus, option A is incorrect as it would hinder perfusion in the affected extremities.
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During the last 30 days, an elderly client has exhibited a progressively decreasing appetite, is spending increasing amounts of daytime hours in bed, and refuses to participate in planned daytime activities. Which action should the practical nurse take?
- A. Record the findings and report the symptoms to the charge nurse
- B. Ask the family members to visit more often to stimulate the patient
- C. Motivate the client by offering favorite foods as a prize
- D. Withhold any medications that may cause side effects
Correct Answer: A
Rationale: The practical nurse should record the findings and report the symptoms to the charge nurse. These behaviors may indicate a serious underlying condition such as depression or physical illness. By reporting to the charge nurse, the client can receive appropriate assessment and intervention promptly. Choice B is incorrect as family visits may not address the root cause of the symptoms. Choice C is incorrect as it oversimplifies the situation and may not be effective in addressing the underlying issue. Choice D is incorrect because withholding medications without proper assessment and guidance can be harmful to the client's health.
Which of the following is the best method for confirming nasogastric tube placement?
- A. Auscultating over the stomach while injecting air
- B. Checking the pH of the aspirate
- C. Observing the patient's response during feeding
- D. Measuring the external length of the tube
Correct Answer: B
Rationale: Checking the pH of the aspirate is the most reliable method to confirm nasogastric tube placement as it provides direct evidence of the tube's location in the stomach. When the pH is acidic (pH < 5), it indicates that the tube is correctly placed in the stomach. Auscultating over the stomach while injecting air may not always be accurate, as the sound can be misleading due to various factors. Observing the patient's response during feeding is not a definitive method for confirming tube placement, as it can be influenced by other factors. Measuring the external length of the tube does not ensure correct placement within the GI tract and can be affected by external factors like patient anatomy.
The nurse is caring for a client with pericarditis. Which of the following nursing interventions will promote comfort for the client?
- A. Auscultating the client's heart sounds
- B. Provide the client with a diversionary activity
- C. Encourage deep breathing
- D. Maintain a patent intravenous access
Correct Answer: B
Rationale: Providing a diversionary activity is the most appropriate nursing intervention to promote comfort for a client with pericarditis. This intervention helps to distract the patient and reduce discomfort by focusing their attention elsewhere. Auscultating heart sounds, while important for monitoring the condition, does not directly address the client's comfort. Encouraging deep breathing can be beneficial for some conditions but may not be specifically aimed at promoting comfort in pericarditis. Maintaining a patent intravenous access is essential for treatment access and management of the condition, but it does not directly promote comfort for the client.
An older client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The PN notes that in the evening this client often becomes restless, confused, and agitated. Which intervention is most important for the PN to implement?
- A. Ask family members to remain with the client in the evenings from 5 to 8 pm
- B. Administer a prescribed PRN benzodiazepine at the onset of a confused state
- C. Ensure that the client is assigned to a room close to the nurses' station
- D. Postpone administration of nighttime medications until after 11 pm
Correct Answer: C
Rationale: Sundowning, a phenomenon where dementia symptoms worsen in the evening, can be managed by ensuring the client is close to the nurses' station for frequent monitoring and quick intervention, if necessary. This reduces the risk of harm and helps manage agitation. Asking family members to remain with the client may not always be feasible and does not address the need for close monitoring. Administering benzodiazepines should not be the first-line intervention for sundowning as it can increase the risk of falls and other adverse effects. Postponing medication administration may disrupt the client's routine and potentially worsen symptoms.
Based on the computer documentation in the EMR, which action should the PN implement?
- A. Give the rubella vaccine subcutaneously
- B. Observe the mother breastfeeding her infant
- C. Call the nursery for the infant's blood type results
- D. Administer hydrocodone/acetaminophen one tablet for pain
Correct Answer: A
Rationale: The rubella vaccine is crucial for preventing rubella infection, which can cause severe congenital disabilities if contracted during pregnancy. Administering the vaccine subcutaneously is the correct action based on EMR documentation. Observing breastfeeding, calling the nursery for blood type results, and administering pain medication are not indicated by the EMR documentation and are not relevant to the situation described in the question.