Nokea
A client just received the first dose of lisinopril. Which of the following is an appropriate nursing intervention?
- A. Place the client on cardiac monitoring
- B. Monitor the client's oxygen saturation level
- C. Provide standby assistance when getting out of bed
- D. Encourage foods high in potassium
Correct Answer: C
Rationale: The correct answer is to provide standby assistance when getting out of bed. Lisinopril can cause first-dose hypotension, leading to dizziness and increasing the risk of falls. Standby assistance helps ensure the client's safety when mobilizing. Placing the client on cardiac monitoring (choice A) is not necessary unless there are specific indications for cardiac monitoring. Monitoring oxygen saturation (choice B) is not directly related to the side effects of lisinopril. Encouraging foods high in potassium (choice D) is not the most immediate or appropriate intervention following the administration of lisinopril.
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A nurse on an acute med-surgical unit is performing assessments on a group of clients. Which is the highest priority?
- A. Client with surgical hypoparathyroidism and positive Trousseau's sign
- B. Client with Clostridium difficile and acute diarrhea
- C. Client with acute kidney injury and low urine specific gravity
- D. Client with oral cancer and reports a sore on his gums
Correct Answer: A
Rationale: The correct answer is A. A positive Trousseau's sign indicates hypocalcemia, which can lead to life-threatening complications like tetany or laryngospasm, making it the highest priority. Choices B, C, and D, while important, do not pose immediate life-threatening risks compared to the potential complications of severe hypocalcemia seen in a client with surgical hypoparathyroidism and a positive Trousseau's sign.
A nurse is caring for a client in the second trimester of pregnancy and asks how to treat constipation. Which of the following statements by the nurse is appropriate?
- A. Decrease intake of vitamins and supplements to every other day
- B. Eat 15 g of fiber per day
- C. Consume 48 ounces of water each day
- D. Drink hot water with lemon juice each morning
Correct Answer: D
Rationale: The correct answer is D. Drinking hot water with lemon juice in the morning is a natural and safe way to stimulate bowel movements and relieve constipation during pregnancy. Option A is incorrect as vitamins and supplements should not be decreased without consulting a healthcare provider, especially during pregnancy. Option B is inadequate as the recommended daily fiber intake during pregnancy is higher than 15g. Option C, while important for overall health, does not directly address constipation relief in pregnancy.
A nurse is caring for a client recovering from bowel surgery who has a nasogastric (NG) tube connected to low intermittent suction. Which of the following assessment findings should indicate to the nurse that the NG tube may not be functioning properly?
- A. Drainage fluid is greenish-yellow
- B. Aspirate pH of 3
- C. Abdominal rigidity
- D. Air bubbles noted in the NG tube
Correct Answer: C
Rationale: Abdominal rigidity can indicate a serious complication, such as a blockage or infection, requiring immediate intervention to determine if the NG tube is functioning properly. Choices A, B, and D are not indicative of a malfunctioning NG tube. Greenish-yellow drainage fluid may be normal, an aspirate pH of 3 is within the expected range for gastric contents, and air bubbles in the NG tube are not abnormal as long as they are moving.
A nurse in a mental health facility receives a change-of-shift report on four clients. Which of the following clients should the nurse assess first?
- A. Client placed in restraints for aggressive behavior
- B. A new client with a history of a 4.5 kg weight loss in the past two months
- C. Client who received a PRN dose of haloperidol 2 hours ago for increased anxiety
- D. Client who will be receiving his first ECT treatment today
Correct Answer: A
Rationale: A client in restraints due to aggressive behavior needs immediate assessment to ensure safety and well-being. The nurse should assess this client first to address any potential risks, such as circulation issues, skin integrity problems, and ongoing agitation. Choices B, C, and D do not present immediate safety concerns that require urgent assessment compared to a client restrained for aggressive behavior.
A nurse is assessing a client who is 12 hours post-surgery. The client has an indwelling urinary catheter, and the nurse notes a urinary output of 15 mL/hr. Which of the following interventions should the nurse implement first?
- A. Irrigate the catheter
- B. Assess the patency of the catheter
- C. Increase the IV fluid rate
- D. Notify the provider
Correct Answer: B
Rationale: The nurse should first assess the patency of the catheter to ensure that the low output is not caused by a blockage. It is crucial to rule out any obstructions before considering other interventions. Irrigating the catheter without verifying patency may worsen the situation if there is a blockage. Increasing IV fluid rate may not address the underlying issue if the problem lies with the catheter. Notifying the provider should come after ensuring the catheter's patency.