Nokea
The client has acute pancreatitis. Which nursing intervention is the highest priority?
- A. Administer pain medication as prescribed.
- B. Monitor the client's serum amylase and lipase levels.
- C. Encourage oral intake of clear liquids.
- D. Assess the client's bowel sounds every 4 hours.
Correct Answer: A
Rationale: The correct answer is A: Administer pain medication as prescribed. This is the highest priority because acute pancreatitis is a painful condition, and managing pain is crucial for the client's comfort and well-being. Pain control also helps reduce stress on the pancreas and can aid in preventing complications.
Choice B is incorrect because while monitoring serum amylase and lipase levels is important in diagnosing pancreatitis and assessing response to treatment, it is not the highest priority intervention.
Choice C is incorrect as encouraging oral intake of clear liquids may exacerbate pancreatitis symptoms and lead to further complications.
Choice D is incorrect as assessing bowel sounds, while important for monitoring gastrointestinal function, is not the highest priority in the acute management of pancreatitis.
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A client with a severe head injury is admitted to the intensive care unit (ICU). Which finding should the nurse report to the healthcare provider immediately?
- A. Urine output of 100 mL/hour.
- B. Intracranial pressure (ICP) of 20 mm Hg.
- C. Respiratory rate of 12 breaths/minute.
- D. Mean arterial pressure (MAP) of 70 mm Hg.
Correct Answer: B
Rationale: The correct answer is B: Intracranial pressure (ICP) of 20 mm Hg. Elevated ICP can lead to increased intracranial pressure, which can further damage brain tissue and impair cerebral perfusion. This is a critical finding that requires immediate intervention to prevent further brain damage.
A: Urine output of 100 mL/hour is within the normal range and does not pose an immediate threat to the client's condition.
C: Respiratory rate of 12 breaths/minute is within normal limits and does not indicate an immediate concern.
D: Mean arterial pressure (MAP) of 70 mm Hg is within the normal range for most adults and does not require immediate intervention in this scenario.
A highly successful individual presents to the community mental health center complaining of sleeplessness and anxiety over their financial status. What action should the nurse take to assist this client in diminishing their anxiety?
- A. Encourage them to initiate daily rituals.
- B. Reinforce the reality of their financial situation.
- C. Direct them to drink a glass of red wine at bedtime.
- D. Teach them to limit sugar and caffeine intake.
Correct Answer: D
Rationale: The correct answer is D: Teach them to limit sugar and caffeine intake.
Rationale:
1. Sugar and caffeine intake can exacerbate anxiety and interfere with sleep due to their stimulant effects.
2. Limiting these substances can help regulate the body's energy levels and reduce anxiety symptoms.
3. By teaching the client to limit sugar and caffeine intake, the nurse is addressing the root causes of the client's sleeplessness and anxiety.
Summary:
A: Encouraging daily rituals may provide structure but does not directly address the physiological effects of sugar and caffeine on anxiety.
B: Reinforcing the reality of the financial situation may increase anxiety rather than alleviate it.
C: Drinking red wine at bedtime is not a recommended solution for managing anxiety and sleeplessness.
Which assessment finding indicates a client's readiness to leave the nursing unit for a bronchoscopy?
- A. Client denies allergies to contrast media.
- B. Skin prep to insertion site completed.
- C. On-call sedation administered.
- D. Oxygen at 2 L/minute via nasal cannula.
Correct Answer: C
Rationale: Rationale: Option C, on-call sedation administered, is the correct answer because sedation is essential for bronchoscopy to ensure the client is comfortable and cooperative during the procedure. Sedation helps reduce anxiety and discomfort, making the procedure more tolerable. Options A, B, and D are incorrect as they do not directly indicate readiness for the procedure. Denying allergies to contrast media (A) is important but not specific to bronchoscopy readiness. Skin prep completion (B) is part of the pre-procedure preparation but does not confirm readiness. Oxygen administration (D) is a routine care measure and does not indicate readiness for bronchoscopy.
A client is undergoing chemotherapy and is at risk for developing thrombocytopenia. What precaution should the nurse teach the client to minimize the risk of bleeding?
- A. Use a soft-bristled toothbrush.
- B. Engage in daily aerobic exercise.
- C. Take aspirin for headaches.
- D. Use an electric razor for shaving.
Correct Answer: A
Rationale: The correct answer is A: Use a soft-bristled toothbrush. Chemotherapy can cause low platelet levels, increasing the risk of bleeding. Using a soft-bristled toothbrush can help prevent gum bleeding and trauma to the gums, reducing the risk of bleeding. Engaging in daily aerobic exercise (B) can increase the risk of injury and bleeding for a client with thrombocytopenia. Taking aspirin (C) can further decrease platelet function and increase bleeding risk. Using an electric razor (D) is recommended to prevent skin cuts and bleeding due to the fragile skin associated with chemotherapy-induced thrombocytopenia.
A male infant born at 30-weeks gestation at an outlying hospital is being prepared for transport to a Level IV neonatal facility. His respirations are 90/min, and his heart rate is 150 beats per minute. Which drug is the transport team most likely to administer to this infant?
- A. Ampicillin (Omnipen) 25 mg/kg slow IV push.
- B. Gentamicin sulfate (Garamycin) 2.5 mg/kg IV.
- C. Digoxin (Lanoxin) 20 micrograms/kg IV.
- D. Beractant (Survanta) 100 mg/kg per endotracheal tube.
Correct Answer: D
Rationale: The correct answer is D: Beractant (Survanta) 100 mg/kg per endotracheal tube. In this scenario, the infant's high respiratory rate indicates respiratory distress, likely due to immature lungs. Beractant is a pulmonary surfactant used to treat respiratory distress syndrome in preterm infants by improving lung function and reducing the risk of complications. Administering beractant via endotracheal tube helps deliver the medication directly to the lungs.
Choice A (Ampicillin) is an antibiotic used for treating infections, not respiratory distress. Choice B (Gentamicin) is an antibiotic for infections, not respiratory distress. Choice C (Digoxin) is a cardiac medication for heart conditions, not respiratory distress. Therefore, only choice D addresses the respiratory distress issue in the preterm infant, making it the most appropriate drug for the transport team to administer in this case.