Nokea
A client with a tracheostomy has thick, tenacious secretions. Which intervention should the nurse include in the plan of care?
- A. Encourage the client to drink plenty of fluids.
- B. Perform deep suctioning every 2 to 4 hours.
- C. Increase humidity in the client's room.
- D. Administer a mucolytic agent.
Correct Answer: C
Rationale: Increasing humidity in the client's room can help liquefy thick secretions and facilitate easier airway clearance in a client with a tracheostomy. Encouraging the client to drink plenty of fluids can be beneficial for overall hydration but may not directly address thick secretions. Deep suctioning every 2 to 4 hours can be harmful and cause trauma to the airway lining. Administering a mucolytic agent should be done under the healthcare provider's order and may not be the initial intervention for thick secretions.
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A client with cirrhosis is admitted with hepatic encephalopathy. Which laboratory value requires immediate intervention?
- A. Serum ammonia level of 80 mcg/dl
- B. Bilirubin level of 3.0 mg/dl
- C. Serum sodium level of 135 mEq/L
- D. Prothrombin time of 18 seconds
Correct Answer: D
Rationale: The correct answer is D. A prothrombin time of 18 seconds is most concerning in a client with hepatic encephalopathy as it indicates impaired liver function and an increased risk of bleeding. This requires immediate intervention to prevent bleeding complications. Choice A, serum ammonia level of 80 mcg/dl, is elevated but not as urgent as the abnormal prothrombin time. Choice B, bilirubin level of 3.0 mg/dl, is elevated but does not directly indicate an urgent need for intervention in this situation. Choice C, serum sodium level of 135 mEq/L, is within the normal range and does not require immediate intervention.
A client with diabetes mellitus is admitted with a blood glucose level of 640 mg/dl and is unresponsive. Which intervention should the nurse implement first?
- A. Administer 50% dextrose IV push
- B. Administer IV fluids as prescribed
- C. Check the client's blood glucose level
- D. Prepare the client for immediate dialysis
Correct Answer: B
Rationale: Administering IV fluids as prescribed is the priority intervention in a client with a blood glucose level of 640 mg/dl and unresponsiveness. Severe hyperglycemia can lead to dehydration and electrolyte imbalances, and administering IV fluids can help manage hyperglycemia and prevent further complications. Administering dextrose IV push (Choice A) can exacerbate hyperglycemia in this scenario. Checking the client's blood glucose level (Choice C) is important but not the immediate priority when the client is unresponsive. Immediate dialysis (Choice D) is not indicated as the first intervention for hyperglycemia.
A client with a history of atrial fibrillation is prescribed warfarin (Coumadin). Which laboratory value should the nurse monitor closely?
- A. Prothrombin time (PT)
- B. Hemoglobin level
- C. International Normalized Ratio (INR)
- D. Serum sodium level
Correct Answer: C
Rationale: The correct answer is C, International Normalized Ratio (INR). The INR should be closely monitored in a client prescribed warfarin (Coumadin) to assess the effectiveness and safety of anticoagulation therapy. Monitoring the INR helps ensure that the client is within the therapeutic range for anticoagulation, reducing the risk of bleeding or clotting complications. Prothrombin time (A) is used to calculate the INR and monitor the effectiveness of warfarin therapy. Hemoglobin level (B) is important but not the primary lab value to monitor when a client is on warfarin. Serum sodium level (D) is not directly related to monitoring warfarin therapy.
The nurse is caring for a 17-year-old male who fell 20 feet 5 months ago while climbing the side of a cliff and has been in a sustained vegetative state since the accident. Which intervention should the nurse implement?
- A. Talk directly to the adolescent while providing care
- B. Maintain silence during care to avoid overstimulation
- C. Play soothing music in the background
- D. Limit visitors to immediate family only
Correct Answer: A
Rationale: Talking directly to the adolescent is the most appropriate intervention in this scenario. It helps maintain a sense of connection and respect, even if the response is not evident. Maintaining silence may lead to isolation and hinder any potential communication attempts. Playing soothing music may not provide the personal interaction needed for connection. Limiting visitors to immediate family only may deprive the patient of diverse interactions that could be beneficial for their emotional well-being.
The nurse is assessing a client with left-sided heart failure. Which assessment finding requires immediate intervention?
- A. Jugular venous distention
- B. Shortness of breath
- C. Crackles in the lungs
- D. Peripheral edema
Correct Answer: C
Rationale: In a client with left-sided heart failure, crackles in the lungs are a critical assessment finding that necessitates immediate intervention. Crackles indicate pulmonary congestion, a sign of worsening heart failure that requires prompt attention to prevent respiratory distress. Jugular venous distention, shortness of breath, and peripheral edema are also common in heart failure, but crackles specifically point to pulmonary involvement and the urgent need for intervention.