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The PN identifies an electrolyte imbalance, exhibited by changes in mental status, and an elevated blood pressure for a client with progressive heart disease. Which intervention should the PN implement first?
- A. Record usual eating patterns
- B. Evaluate for muscle cramping
- C. Document abdominal girth
- D. Elevate both legs on pillows
Correct Answer: B
Rationale: Evaluating for muscle cramping, which is a sign of electrolyte imbalance, is crucial in this scenario. Electrolyte imbalances, especially involving potassium or calcium, can lead to serious complications such as arrhythmias or seizures, which need immediate attention. Recording eating patterns (choice A) may be important for overall assessment but is not the priority in this situation. Documenting abdominal girth (choice C) and elevating legs on pillows (choice D) are not directly related to addressing the immediate concern of electrolyte imbalance and its potential complications.
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After administering pantoprazole to a client with gastroesophageal reflux disease (GERD), which statement by the client indicates to the nurse that the medication is producing the desired effect?
- A. After eating my meal, I did not experience any heartburn
- B. I have a great appetite and am feeling really hungry
- C. I should increase the amount of vitamin C in my diet
- D. While eating, I had no difficulty swallowing any of the foods
Correct Answer: A
Rationale: The correct answer is A. Pantoprazole reduces stomach acid production, thus preventing the occurrence of heartburn after meals, which is a common symptom of GERD. Choice B is incorrect because an increased appetite and hunger are not indicators of the desired effect of pantoprazole. Choice C is unrelated to the medication's effect on GERD symptoms. Choice D is also incorrect because the absence of difficulty swallowing is not a specific indicator of pantoprazole's effectiveness in treating GERD.
After adding feeding solution to a client's tube feeding system as seen in the picture, what action should the PN take next?
- A. Remove the air from the solution bag
- B. Obtain a piston syringe and irrigation set
- C. Record the solution added as fluid intake
- D. Calculate the rate of flow of the solution
Correct Answer: B
Rationale: After adding feeding solution, obtaining a piston syringe and irrigation set is necessary to flush the feeding tube and ensure patency before starting the feeding. This helps prevent blockages and ensures proper delivery of the nutritional solution. Option A is incorrect because removing air from the solution bag is not the immediate next step after adding the feeding solution. Option C is incorrect as recording the solution added as fluid intake is important but not the immediate next step. Option D is incorrect as calculating the rate of flow of the solution is not the next step after adding the feeding solution.
The nurse and UAP enter a client's room and find the client lying on the bed. The nurse determines that the client is unresponsive. Which instruction should the nurse give the UAP first?
- A. Obtain emergency help
- B. Feel for a carotid pulse
- C. Bring a glucometer to the room
- D. Check the blood pressure
Correct Answer: A
Rationale: The correct answer is to instruct the UAP to obtain emergency help first. In a situation where a client is unresponsive, the priority is to ensure that help is summoned promptly. This allows for the availability of necessary resources and assistance for resuscitation or other emergency interventions. Feeling for a carotid pulse or checking the blood pressure can be important assessments but are secondary to obtaining immediate help. Bringing a glucometer to the room, while relevant in certain situations, is not the priority when the client's unresponsiveness indicates a need for urgent intervention.
In which condition is the 'butterfly rash' most commonly seen?
- A. Systemic lupus erythematosus
- B. Rheumatoid arthritis
- C. Psoriasis
- D. Dermatomyositis
Correct Answer: A
Rationale: The correct answer is A: Systemic lupus erythematosus (SLE). The 'butterfly rash' across the cheeks and nose is a classic sign of SLE, an autoimmune disease. This rash is a key dermatological manifestation of SLE, often triggered or worsened by exposure to sunlight. Choices B, C, and D are incorrect because the 'butterfly rash' is not commonly associated with rheumatoid arthritis, psoriasis, or dermatomyositis.
Which is the most important safety measure when administering a medication through a patient's central venous catheter (CVC)?
- A. Using a sterile technique
- B. Ensuring correct placement of the CVC
- C. Flushing the CVC with saline after administration
- D. Monitoring for signs of infection
Correct Answer: B
Rationale: The most important safety measure when administering a medication through a patient's central venous catheter (CVC) is ensuring the correct placement of the CVC. This is crucial to prevent complications such as extravasation, infection, or improper drug delivery. While using a sterile technique, flushing the CVC with saline after administration, and monitoring for signs of infection are all important aspects of CVC care, ensuring the correct placement of the catheter takes precedence as it directly impacts patient safety during medication administration.