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A nurse is caring for an 82-year-old client in the ER who has an oral body temperature of 38.3°C (101°F), a pulse rate of 114/min, & a respiratory rate of 22/min. He is restless & his skin is warm. Which of the following are appropriate nursing interventions for this client? Select all.
- A. Obtain culture specimens before initiating antimicrobials
- B. Restrict the client's oral fluid intake
- C. Encourage the client to limit activity & rest
- D. Allow the client to shiver to dispel excess heat
- E. Assist the client with oral hygiene frequently
Correct Answer: A, C, E
Rationale: Correct Answer: A, C, E
Rationale:
A: Obtaining culture specimens before initiating antimicrobials is crucial to identify the specific pathogen causing the infection and guide appropriate treatment.
C: Encouraging the client to limit activity & rest helps conserve energy and promote recovery in the presence of infection.
E: Assisting the client with oral hygiene frequently helps prevent further infection and maintain oral health, which is important in the elderly population.
Incorrect Choices:
B: Restricting the client's oral fluid intake is not appropriate as hydration is essential, especially in the presence of fever and infection.
D: Allowing the client to shiver to dispel excess heat is not recommended as it can lead to increased metabolic demand and discomfort for the client.
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A nurse is caring for a client who is receiving morphine via a PCA infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device?
- A. I'll wait to use the device until it's absolutely necessary.
- B. I'll be careful about pushing the button so I don't get an overdose.
- C. I should tell the nurse if the pain doesn't stop after I use this device.
- D. I will ask my son to push the dose button when I am sleeping.
Correct Answer: C
Rationale: The correct answer is C because the client demonstrating understanding of using the PCA infusion device should know to communicate with the nurse if the pain persists after using the device. This indicates the client's awareness of the importance of monitoring pain levels and seeking help if needed. Choice A does not demonstrate understanding of the device's purpose or functionality. Choice B shows awareness of the risk of overdose but not necessarily how to use the device correctly. Choice D is incorrect as the client should be the one responsible for administering the medication through the PCA device.
A nurse is preparing to administer 0.9% sodium chloride (0.9% NaCl) 250 mL IV to infuse over 30 minutes. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?
Correct Answer: 83
Rationale: To calculate the drip rate, we can use the formula: Drip rate = (Volume to be infused in gtt) / Time in minutes. In this case, the volume to be infused is 250 mL, and the time is 30 minutes. Convert 250 mL to drops: 250 mL x 10 gtt/mL = 2500 gtt. Now, divide 2500 gtt by 30 minutes to get 83.33 gtt/min. Since we can't administer a fraction of a drop, we round down to the nearest whole number, which is 83 gtt/min. This rate ensures the 0.9% NaCl solution is administered accurately over the specified time. Other choices are incorrect because they do not result from the correct calculation based on the given information.
A nurse who is admitting a client who has a fractured femur obtains a blood pressure reading of 140/94 mmHg. The client denies any history of hypertension. Which of the following actions should the nurse take next?
- A. Request a prescription for an antihypertensive medication
- B. Ask the client if she is having pain
- C. Request a prescription for an anti-anxiety medication
- D. Return in 30 minutes to recheck the client's BP
Correct Answer: B
Rationale: The correct answer is B. When a client with a fractured femur presents with an elevated blood pressure reading, it is important for the nurse to first assess if the client is in pain. Pain can cause an increase in blood pressure due to stress and sympathetic nervous system activation. Addressing pain management is crucial to providing holistic care and may help lower the blood pressure without the need for antihypertensive medications. Requesting an antihypertensive medication (choice A) without addressing the potential pain issue would not be appropriate at this time. Similarly, requesting an anti-anxiety medication (choice C) without further assessment would not address the underlying cause of the elevated blood pressure. Returning in 30 minutes to recheck the client's BP (choice D) is not as proactive as addressing the potential pain issue immediately.
A nurse in a provider's office is preparing to assess a young adult male client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? Select all.
- A. A concave thoracic spine posteriorly
- B. An exaggerated lumbar curvature
- C. A concave lumbar spine posteriorly
- D. An exaggerated thoracic curvature
- E. Muscles slightly larger on his dominant side
Correct Answer: C, E
Rationale: Correct Answer: C, E
Rationale:
C: A concave lumbar spine posteriorly is expected in a young adult male due to the normal lordotic curve in the lumbar region for weight-bearing support.
E: Muscles slightly larger on his dominant side is an expected finding as asymmetry in muscle size and strength is common due to dominant limb use.
Incorrect Choices:
A: A concave thoracic spine posteriorly is not a normal finding and may indicate poor posture or spinal deformity.
B: An exaggerated lumbar curvature is not expected in a young adult male and may suggest a potential spinal issue.
D: An exaggerated thoracic curvature is not typical in a young adult male and may indicate abnormal spinal curvature.
A nurse manager of a med-surg unit is assigning care responsibilities for the oncoming shift. A client is awaiting transfer back to the unit from the PACU following thoracic surgery. To which staff member should the nurse assign this client?
- A. Charge nurse
- B. RN
- C. LPN
- D. AP
Correct Answer: B
Rationale: The correct answer is B: RN. A registered nurse (RN) is the most appropriate staff member to care for a client awaiting transfer from the PACU following thoracic surgery due to their advanced training and skill set. RNs are qualified to assess, monitor, and manage complex post-operative care needs, including respiratory status, pain management, and hemodynamic stability. Charge nurses may have administrative duties and may not be available to provide direct patient care. LPNs have a more limited scope of practice and may not have the necessary skills to care for a post-thoracic surgery patient. Advanced practice nurses (AP) typically have specialized roles and responsibilities that may not align with providing direct care in this situation.