Nokea
A 16-year-old client is in the emergency department for treatment of minor injuries from a car accident. A crisis nurse is with her because she became hysterical and was saying, 'It's my fault. My Mom is going to kill me. I don't even have a way home.' Which of the following should be the nurse's initial intervention?
- A. Hold her hands and say, 'Slow down. Take a deep breath.'
- B. Say, 'Calm down. The police can take you home.'
- C. Put a hand on her shoulder and say, 'It wasn't your fault.'
- D. Say, 'Your mother is not going to kill you. Stop worrying.'
Correct Answer: A
Rationale: This intervention calms the client's hysteria using physical touch and breathing techniques, helping her regain composure before addressing other concerns.
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A client just been diagnosed with acute kidney injury has a serum potassium level of 6.1 mEq/L (6.1 mmol/L). Which action should the nurse take immediately?
- A. Check the sodium level.
- B. Call the primary health care provider.
- C. Encourage an extra 500 mL of fluid intake.
- D. Teach the client about foods low in potassium.
Correct Answer: B
Rationale: The client with hyperkalemia is at risk of developing cardiac dysrhythmias and resultant cardiac arrest. Because of this, the primary health care provider must be notified at once so that the client may receive definitive treatment. The nurse might also check the result of a serum sodium level, but this is not a priority action of the nurse. Fluid intake would not be increased because it would contribute to fluid overload and would not effectively lower the serum potassium level. Dietary teaching may be necessary at some point, but this action is not the priority.
The nurse is caring for a child with a head injury. Place the following assessments in order of priority, starting with the nursing assessment the nurse should perform first.
- A. Vital signs.
- B. Decreased urine output.
- C. Level of consciousness.
- D. Motor strength.
Correct Answer: C,A,D,B
Rationale: Level of consciousness is the priority to assess neurological status, followed by vital signs for stability, motor strength for deficits, and urine output for systemic effects.
The nurse is caring for a client with a history of chronic obstructive pulmonary disease who is prescribed salmeterol (Serevent). The nurse should instruct the client to:
- A. Use the inhaler as needed for shortness of breath.
- B. Rinse the mouth after using the inhaler.
- C. Shake the inhaler before use.
- D. Use the inhaler twice daily.
Correct Answer: D
Rationale: Salmeterol is a long-acting bronchodilator used twice daily for maintenance therapy in COPD.
The nurse is caring for a client who is having an acute asthma attack. The nurse should notify the physician of which of the following?
- A. Loud wheezing.
- B. Tenacious, thick sputum.
- C. Decreased breath sounds.
- D. Persistent cough.
Correct Answer: C
Rationale: Decreased breath sounds indicate severe airway obstruction in an asthma attack, requiring immediate physician notification.
The nurse is monitoring the function of a client's chest tube that is attached to a chest drainage system. The nurse notes that the fluid in the water-seal chamber is below the 2-cm mark. What should the nurse determine based on this finding?
- A. There is a leak in the system.
- B. Suction should be added to the system.
- C. This is caused by client pneumothorax.
- D. Water should be added to the chamber.
Correct Answer: D
Rationale: The water-seal chamber should be filled to the 2-cm mark to provide an adequate water seal between the external environment and the client's pleural cavity. The water seal prevents air from reentering the pleural cavity. Because evaporation of water can occur, the nurse should remedy this problem by adding sterile water until the level is again at the 2-cm mark. The other interpretations are incorrect.