Nokea
A 5-week-old infant who developed projectile vomiting over the last two weeks is diagnosed with hypertrophic pyloric stenosis. Which intervention should the nurse plan to implement?
- A. Instruct the mother to give the child sugar water only
- B. Maintain intravenous fluid therapy per prescription
- C. Provide Pedialyte feedings via the nasogastric tube
- D. Offer the infant Pedialyte feedings every 2 hours
Correct Answer: B
Rationale: Maintaining intravenous fluid therapy is crucial for managing dehydration and electrolyte imbalances caused by the vomiting in hypertrophic pyloric stenosis. Instructing the mother to give sugar water only (Choice A) is not appropriate as it does not address the dehydration and electrolyte imbalances adequately. Providing Pedialyte feedings via the nasogastric tube (Choice C) may not be sufficient to manage the severe fluid and electrolyte losses caused by the condition. Offering Pedialyte feedings every 2 hours (Choice D) may not be as effective as maintaining intravenous fluid therapy, especially in cases where rapid rehydration is necessary.
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Why is it important to initiate nursing interventions that promote good nutrition, rest, exercise, and stress reduction for clients diagnosed with an HIV infection?
- A. Prevent the spread of infection to others
- B. Improve the function of the immune system
- C. Increase the ability to carry out activities of daily living
- D. Promote a feeling of general well-being
Correct Answer: B
Rationale: The correct answer is B: 'Improve the function of the immune system.' Initiating interventions focusing on good nutrition, rest, exercise, and stress reduction aims to enhance the immune system function in clients with HIV infection. For individuals with HIV, maintaining a strong immune system is crucial in fighting the virus and preventing opportunistic infections. Choices A, C, and D are important aspects of care but are secondary to the primary goal of boosting the immune system to combat the effects of the HIV virus.
A client with intestinal obstructions has a nasogastric tube to low intermittent suction and is receiving an IV of lactated Ringer's at 100 ml/H. Which finding is most important for the nurse to report to the healthcare provider?
- A. Gastric output of 900 mL in the last 24 hours
- B. Serum potassium level of 3.1 mEq/L or mmol/L (SI)
- C. Increased blood urea nitrogen (BUN)
- D. 24-hour intake at the current infusion rate
Correct Answer: B
Rationale: The most crucial finding to report to the healthcare provider in this scenario is a serum potassium level of 3.1 mEq/L. Hypokalemia can lead to serious complications, including cardiac issues. Gastric output, increased BUN, and monitoring the 24-hour intake are essential but do not pose an immediate risk as hypokalemia does in this situation.
A man calls the hospital and asks to talk with the nurse about his girlfriend who was extremely intoxicated on admission and is receiving services for detoxification. He knows that she is in the facility and asks the nurse about her condition. What is the nurse's best response?
- A. ''I can only report that the client is in satisfactory condition.''
- B. ''Let me give you the telephone number for her room.''
- C. ''I cannot acknowledge if a client is here or not.''
- D. ''I will have the nurse who is working with her call you.''
Correct Answer: C
Rationale: The nurse must adhere to confidentiality rules and cannot confirm the presence or condition of the client. Choice A is incorrect because disclosing the client's condition breaches confidentiality. Choice B is wrong as it reveals the client's room number, which is also a breach of confidentiality. Choice D is not the best response as it involves sharing information about the client without verifying the caller's identity or relationship to the client.
The charge nurse of a cardiac telemetry unit is assigning client care to a registered nurse (RN) and a practical nurse (PN). Which client should be assigned to the RN?
- A. One day after a permanent pacemaker insertion, a client's telemetry monitor shows a pacer rhythm.
- B. Two hours after undergoing cardioversion, a client's telemetry monitor shows a normal sinus rhythm.
- C. A client started on carvedilol the previous day for heart failure has controlled atrial fibrillation.
- D. Four hours after admission, a client with syncope shows complete heart block on the telemetry monitor.
Correct Answer: D
Rationale: The correct answer is D because complete heart block is a critical condition that requires immediate assessment and management by a registered nurse (RN). In complete heart block, there is a significant conduction disturbance that can lead to serious complications. The RN is better equipped to handle such complex and potentially life-threatening situations. Choices A, B, and C involve less critical conditions that can be managed by a practical nurse (PN) under the supervision of the RN. Therefore, assigning the client with complete heart block to the RN ensures prompt and appropriate intervention.
The nurse is obtaining the medical histories of new clients at a community-based primary care clinic. Which individual has the highest risk for experiencing elder abuse?
- A. A 69-year-old widowed female who lives alone and volunteers at a school
- B. A 95-year-old ambulatory male who resides in a nursing home in a small town
- C. A 78-year-old female on a fixed income who lives with her relatives
- D. An 81-year-old male with diabetes who lives with his wife of 52 years
Correct Answer: C
Rationale: Elder abuse risk is higher in individuals who live with relatives and are on a fixed income as these factors can contribute to vulnerability. Living with relatives may expose the individual to potential abusive situations within the family dynamics. Additionally, being on a fixed income may limit financial independence and increase dependency on others, potentially leading to financial abuse. The other options, such as living alone and volunteering, residing in a nursing home, or living with a long-term spouse, do not inherently pose the same level of risk factors for elder abuse as living with relatives on a fixed income.