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A client who has a head injury is transported to the emergency department. Which assessment does the emergency department nurse perform immediately?
- A. Pupil response
- B. Motor function
- C. Respiratory status
- D. Short-term memory
Correct Answer: C
Rationale: In a client with a head injury, assessing the respiratory status is the priority as airway and breathing are essential for life. Immediate attention to respiratory status is crucial to ensure adequate oxygenation. While assessing pupil response and motor function are also important in head injuries, ensuring the client's ability to breathe takes precedence. Short-term memory assessment is not a priority in the emergent phase of care for a client with a head injury.
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The nurse teaches a client who is newly diagnosed with coronary artery disease. Which instruction does the nurse include to minimize complications of this disease?
- A. "Rest is the best medicine at this time. Do not start an exercise program."?
- B. "You are a man; therefore, there is nothing you can do to minimize your risks."?
- C. "You should talk to your provider about medications to help you quit smoking."?
- D. "Decreasing the carbohydrates in your diet will help you lose weight."?
Correct Answer: C
Rationale: The correct answer is to advise the client to talk to their provider about medications to help quit smoking. Smoking is a major risk factor for coronary artery disease, and quitting smoking can significantly reduce the risk of complications. Choice A is incorrect because exercise is beneficial for managing coronary artery disease, but should be started gradually and under guidance. Choice B is incorrect and inappropriate as it undermines the client's ability to take control of their health. Choice D is incorrect because while a balanced diet is important, specifically targeting carbohydrates alone may not be the most effective or healthy approach for managing coronary artery disease.
A female client with deteriorating neurologic function states, "I am worried I will not be able to care for my young children."? How does the nurse respond?
- A. "Caring for your children is a priority. You may not want to ask for help, but you have to."?
- B. "Our community has resources that may help you with some household tasks so you have energy to care for your children."?
- C. "You seem distressed. Would you like to talk to a psychologist about adjusting to your changing status?"?
- D. "Give me more information about what worries you, so we can see if we can do something to make adjustments."?
Correct Answer: D
Rationale: When a client expresses worry about not being able to care for her children due to deteriorating neurologic function, the most appropriate response from the nurse is to gather more information from the client. This open-ended approach allows the nurse to better understand the client's specific concerns and needs, leading to tailored interventions and support. Choice A is dismissive and may make the client feel guilty for needing help. Choice B focuses on external resources without addressing the client's worries directly. Choice C suggests a psychological referral without exploring the client's concerns further. Therefore, the correct response is to gather more information to provide personalized support.
To obtain a sterile urine specimen from a client with a Foley catheter, the nurse begins by applying a clamp to the drainage tubing distal to the injection port. What does the nurse do next?
- A. Clamp another section of the tube to create a fixed sample section for retrieval.
- B. Insert a syringe into the injection port and aspirate the quantity of urine required.
- C. Clean the injection port cap of the drainage tubing with povidone-iodine solution.
- D. Withdraw 10 mL of urine and discard it; then withdraw 10 mL more for the sample.
Correct Answer: C
Rationale: After clamping the drainage tubing, the next step in obtaining a sterile urine specimen from a client with a Foley catheter is to clean the injection port cap of the drainage tubing with povidone-iodine solution. This cleaning step helps prevent contamination of the urine sample. Clamping another section of the tube isn't necessary and may not be a standard practice. Inserting a syringe into the injection port to aspirate urine isn't the correct step at this point. Withdrawing 10 mL of urine and discarding it before collecting the sample isn't appropriate and may lead to an inaccurate sample.
The healthcare professional is assessing a client with hypertension. Which client outcome is indicative of effective hypertension management?
- A. Absence of pedal edema in the lower legs.
- B. Absence of complaints of sexual dysfunction.
- C. No indication of renal impairment.
- D. Blood pressure reading of 148/94 mm Hg.
Correct Answer: C
Rationale: The correct answer is 'No indication of renal impairment.' Effective hypertension management aims to prevent complications such as renal impairment. Checking for signs of kidney issues, like abnormal renal function tests, is crucial in monitoring the client's condition. Choices A, B, and D are not specific indicators of effective hypertension management. Pedal edema, sexual dysfunction, and a single blood pressure reading are important but do not solely determine the effectiveness of managing hypertension.
A client is receiving an IV infusion of an antibiotic. The client calls the nurse feeling uneasy due to congestion. Which action by the nurse is most appropriate?
- A. Elevate the head of the client's bed to 45 degrees
- B. Have another nurse call the Rapid Response Team
- C. Prepare to administer diphenhydramine (Benadryl)
- D. Slow the rate of the IV infusion
Correct Answer: B
Rationale: In this situation, the client's symptoms of congestion and feeling uneasy may indicate an anaphylactic reaction, which can be life-threatening. The most appropriate action is to call the Rapid Response Team to provide immediate assistance and interventions. Elevating the head of the bed, administering diphenhydramine, or slowing the IV infusion rate are not the priority actions in the case of a potential severe allergic reaction. These interventions may delay necessary emergency care and potentially worsen the client's condition.