Nokea
What is the first action the nurse should implement for a client admitted with acute pancreatitis?
- A. Administer intravenous fluids as prescribed
- B. Administer pain medication as prescribed
- C. Place the client on NPO status
- D. Assess the client's abdomen for distention
Correct Answer: C
Rationale: Placing the client on NPO status is the priority action for a client with acute pancreatitis. This step is crucial to rest the pancreas, prevent pancreatic stimulation, and decrease enzyme production. By withholding oral intake, the digestive system is given a chance to rest and recover. Administering intravenous fluids may be necessary but should come after placing the client on NPO status. Pain medication can be administered once the client is stabilized. Assessing the client's abdomen for distention is important but is not the initial priority in managing acute pancreatitis.
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The nurse observes an adolescent client preparing to administer a prescribed corticosteroid medication using a metered dose inhaler. What action should the nurse take?
- A. Remind the client to hold their breath after inhaling the medication
- B. Confirm that the client has correctly shaken the inhaler
- C. Affirm that the client has correctly positioned the inhaler
- D. Ask the client if they have a spacer to use for this medication
Correct Answer: A
Rationale: Corrected Rationale: Reminding the client to hold their breath after inhaling the medication is crucial as it helps ensure the medication is absorbed into the lungs. Option B is incorrect because shaking the inhaler is not directly related to the client's inhalation technique. Option C is incorrect as correct positioning of the inhaler is important but not the immediate action needed in this situation. Option D is incorrect as asking about the spacer is not the most relevant action to take at this moment.
A female client who is admitted to the mental health unit for opiate dependency is receiving clonidine 0.1 mg PO for withdrawal symptoms. The client begins to complain of feeling nervous and tells the nurse that her bones are itching. Which finding should the nurse identify as a contraindication for administering the medication?
- A. Blood pressure 90/76 mm Hg.
- B. Heart rate of 85 bpm.
- C. Respiratory rate of 20 breaths/minute.
- D. Temperature of 99°F (37.2°C).
Correct Answer: A
Rationale: Clonidine can lower blood pressure, so a BP of 90/76 mm Hg may indicate that it is unsafe to administer another dose. In this situation, the low blood pressure reading indicates that the client is already experiencing hypotension, which is a common side effect of clonidine. Administering more clonidine could further lower the blood pressure, leading to potential complications. The heart rate, respiratory rate, and temperature are within normal limits and do not serve as contraindications for administering clonidine in this scenario.
When assessing a client with left-sided heart failure, which intervention should the nurse implement first?
- A. Administer oxygen therapy as prescribed.
- B. Monitor the client's urine output.
- C. Administer a loop diuretic as prescribed.
- D. Administer morphine as prescribed.
Correct Answer: A
Rationale: Administering oxygen therapy is the initial intervention for a client with left-sided heart failure. This action is crucial in improving oxygen levels and reducing pulmonary congestion. Monitoring urine output is important for assessing renal function in heart failure, but it is not the priority over ensuring adequate oxygenation. Administering loop diuretics helps manage fluid overload but should come after addressing oxygen needs. Morphine may be indicated for pain or anxiety in some cases, but it is not the primary intervention for left-sided heart failure.
The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days. What assessment is most important for the nurse to complete?
- A. Auscultate the client's bowel sounds
- B. Observe for edema around the ankles
- C. Measure the client's capillary glucose level
- D. Count the apical and radial pulses simultaneously
Correct Answer: A
Rationale: The correct answer is to auscultate the client's bowel sounds. Hydromorphone is a potent opioid analgesic that can slow peristalsis and commonly cause constipation. By assessing the client's bowel sounds, the nurse can monitor for any signs of decreased bowel motility or potential constipation. Observing for edema (Choice B) is not directly related to hydromorphone administration. Measuring capillary glucose levels (Choice C) is not the priority in this situation. Counting the apical and radial pulses simultaneously (Choice D) is not specifically indicated in this scenario involving hydromorphone administration.
The nurse is assessing the thorax and lungs of a client who is experiencing respiratory difficulty. Which finding is most indicative of respiratory distress?
- A. Contractions of the sternocleidomastoid muscle.
- B. Respiratory rate of 20 breaths/min
- C. Downward movement of diaphragm with inspiration
- D. A pulse oximetry reading of SpO2 95%
Correct Answer: A
Rationale: The correct answer is A: Contractions of the sternocleidomastoid muscle. Contractions of the sternocleidomastoid muscle suggest that the client is using accessory muscles to breathe, which is a clear sign of respiratory distress. This finding indicates that the client is working harder to breathe, typically seen in conditions like asthma, COPD, or respiratory failure. Choices B, C, and D are not the most indicative of respiratory distress. A respiratory rate of 20 breaths/min falls within the normal range. Downward movement of the diaphragm with inspiration is a normal finding indicating effective diaphragmatic breathing. A pulse oximetry reading of SpO2 95% is within the normal range and does not necessarily indicate respiratory distress.