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A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?
- A. A client who is scheduled for a procedure in 1 hr
- B. A client who received a pain medication 30 min ago for postoperative pain
- C. A client who was just given a glass of orange juice far a low blood glucose level
- D. A client who has 100 mL of fluid remaining in his IV bag
Correct Answer: C
Rationale: The correct answer is C. The nurse should assess the client who just drank orange juice for a low blood glucose level first because hypoglycemia can lead to serious complications like seizures or loss of consciousness. Assessing and addressing the client's blood glucose level promptly is crucial to prevent harm.
Choice A is not the priority as the client scheduled for a procedure in 1 hour can wait for assessment until after the client with low blood glucose is evaluated.
Choice B, the client who received pain medication 30 minutes ago, can be assessed after the client with low blood glucose since the medication's effects have likely already taken place.
Choice D, the client with 100 mL of fluid remaining in the IV bag, can also wait for assessment as it does not pose an immediate threat to the client's health compared to low blood glucose.
Therefore, prioritizing the assessment of the client with low blood glucose is crucial to ensure their safety and well-being.
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For which of the following therapeutic effects should the nurse monitor the client?
- A. Deep tendon reflexes 2+
- B. Pulse rate 100/min
- C. Urine output 20 mL/hr
- D. 1+ proteinuria via urine dipstick
Correct Answer: A
Rationale: The correct answer is A: Deep tendon reflexes 2+. Monitoring deep tendon reflexes is essential in assessing neurological function and detecting abnormalities such as hyperreflexia or hyporeflexia. A normal response of 2+ indicates intact neurological pathways. Abnormal reflexes could be indicative of various neurological conditions. Pulse rate, urine output, and proteinuria are important parameters to monitor but are not specifically related to therapeutic effects. Monitoring deep tendon reflexes is crucial for detecting early signs of neurological complications and guiding appropriate interventions.
For each potential provider prescription click to specify if the prescription is anticipated or contraindicated for the client.
- A. Administer famotidine 20 mg via intermittent IV infusion twice daily.
- B. insert an indwelling urinary catheter.
- C. Administer lactated Ringer's 1L via IV bolus.
- D. Insert a nasogastric tube and maintain low intermittent suction.
Correct Answer: A,C,D
Rationale: [Explanation: The correct answer is - A,C,D. Administering famotidine helps reduce stomach acid, beneficial for clients with gastric issues. Lactated Ringer's IV bolus helps with fluid resuscitation. Inserting a nasogastric tube can help with decompression or feeding. Inserting an indwelling urinary catheter is not typically provider-initiated unless medically necessary. Therefore, A, C, and D are anticipated for client care, while B is contraindicated unless specifically indicated.]
Which of the following actions should the nurse include in the plan of care?
- A. Give cromolyn nebulized solution every 8 hr
- B. Administer analgesics on a scheduled basis for the first 24 hr
- C. Apply a warm compress to the operative site once daily
- D. Offer small amounts of clear liquids 6 hr following surgery.
Correct Answer: B
Rationale: The correct answer is B because administering analgesics on a scheduled basis for the first 24 hours post-surgery helps manage pain effectively. Pain management is crucial for patient comfort and promotes early mobilization. Choice A is incorrect because cromolyn nebulized solution is not typically used post-operatively. Choice C is incorrect as applying a warm compress once daily may not provide adequate pain relief. Choice D is incorrect as clear liquids are usually started slowly to prevent nausea and vomiting, not 6 hours post-surgery.
Which of the following actions should the nurse take?
- A. Encourage the client to watch television
- B. Administer a dose of atomoxetine to decrease anxiety
- C. Teach the client how to meditate
- D. Sit with the client to provide a sense of security.
Correct Answer: D
Rationale: Providing a calming presence can help de-escalate panic symptoms.
A nurse is caring for a client who is in a coma and is scheduled for a surgical procedure. Which of the following actions should the nurse take?
- A. Send the unsigned informed consent form to the facility's risk manager.
- B. Determine if the client's health care surrogate is aware of the risks and benefits of the procedure.
- C. Ensure that the client's family supports the provider's decision for surgery,
- D. Determine if the procedure is medically necessary for the client.
Correct Answer: B
Rationale: The correct answer is B: Determine if the client's health care surrogate is aware of the risks and benefits of the procedure. This is important because the client is in a coma and unable to provide informed consent. The health care surrogate acts on behalf of the client and must be fully informed about the procedure to make decisions in the client's best interest. Sending the unsigned consent form to the risk manager (A) is not appropriate as it does not address the issue of informed consent. Ensuring family support (C) is important but does not address the legal requirement of informed consent. While determining medical necessity (D) is important, in this case, the primary concern is obtaining informed consent.