Nokea
A 60-year-old male client is admitted to the hospital with the complaint of right knee pain for the past week. His right knee and calf are warm and edematous. He has a history of diabetes and arthritis. Which neurological assessment action should the nurse perform for this client?
- A. Glasgow Coma Scale
- B. Assess pulses, paresthesia, and paralysis distal to the right knee
- C. Assess pulses, paresthesia, and paralysis proximal to the right knee
- D. Optic nerve using an ophthalmoscope
Correct Answer: B
Rationale: The correct answer is B: Assess pulses, paresthesia, and paralysis distal to the right knee. This is the appropriate action because the client presents with warm, edematous right knee and calf, indicating a potential vascular issue like deep vein thrombosis (DVT). Assessing pulses, paresthesia, and paralysis distal to the right knee helps evaluate circulation and nerve function, crucial in identifying complications of DVT. Glasgow Coma Scale (A) is used to assess consciousness, not relevant in this case. Assessing proximal pulses, paresthesia, and paralysis (C) may not provide accurate information about circulation distal to the knee. Evaluating the optic nerve (D) using an ophthalmoscope is unrelated to the client's presenting symptoms and medical history.
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Which intervention should the nurse implement to enhance the efficacy of the client's asthma medication therapy?
- A. Administer the albuterol inhaler before other inhaled medications.
- B. Provide oxygen via nasal cannula at 2 liters/minute.
- C. Encourage the client to drink three liters of fluids daily.
- D. Keep the client upright during nebulizer therapy.
Correct Answer: A
Rationale: The correct answer is A: Administer the albuterol inhaler before other inhaled medications. Administering albuterol first helps open airways, allowing better absorption of subsequent medications. Option B does not directly enhance medication efficacy. Option C promotes hydration but doesn't affect medication efficacy. Option D does not specifically enhance medication therapy.
The client with chronic kidney disease (CKD) is receiving hemodialysis. Which finding should be reported to the healthcare provider immediately?
- A. Blood pressure of 150/90 mm Hg.
- B. Weight gain of 2 pounds since the last dialysis session.
- C. Blood glucose level of 120 mg/dl.
- D. Potassium level of 6.5 mEq/L.
Correct Answer: D
Rationale: The correct answer is D: Potassium level of 6.5 mEq/L. High potassium levels (hyperkalemia) in CKD patients receiving hemodialysis can lead to serious complications like cardiac arrhythmias or even cardiac arrest. Therefore, it is crucial to report this finding immediately to the healthcare provider for prompt intervention.
Explanation for other choices:
A: Blood pressure of 150/90 mm Hg - While elevated, this blood pressure reading is not an immediate concern unless accompanied by symptoms like chest pain or shortness of breath.
B: Weight gain of 2 pounds since the last dialysis session - While weight gain may indicate fluid retention, it is not an urgent issue unless it is rapid and significant.
C: Blood glucose level of 120 mg/dl - A blood glucose level of 120 mg/dl is within the normal range and does not require immediate action in this context.
A client in labor states, 'I think my water just broke!' The nurse notes that the umbilical cord is on the perineum. What action should the nurse perform first?
- A. Administer oxygen via face mask.
- B. Notify the operating room team.
- C. Place the client in Trendelenburg.
- D. Administer a fluid bolus of 500 ml.
Correct Answer: C
Rationale: The correct answer is C: Place the client in Trendelenburg. This position helps alleviate pressure on the umbilical cord, preventing compression and improving blood flow to the fetus. It is crucial to prioritize this action to prevent fetal distress or compromise. Administering oxygen (A) is important, but not the initial priority. Notifying the operating room team (B) may be necessary but is not the immediate action. Administering a fluid bolus (D) is not indicated in this situation. Placing the client in Trendelenburg is the most appropriate and urgent action to ensure the safety and well-being of the fetus.
A client diagnosed with major depressive disorder refuses to get out of bed, eat, or participate in group therapy. Which intervention is most important for the nurse to implement?
- A. Offer the client high-calorie snacks and frequent small meals.
- B. Ask the client why they are not participating in therapy.
- C. Sit with the client and offer support without demanding participation.
- D. Encourage the client to discuss their feelings of hopelessness.
Correct Answer: C
Rationale: The correct answer is C because sitting with the client and offering support without demanding participation is crucial in building trust and rapport. This approach respects the client's autonomy and allows them to feel supported without pressure. It also creates a safe space for the client to open up when they are ready.
Explanation for why the other choices are incorrect:
A: Offering high-calorie snacks and frequent small meals does not address the core issue of the client's refusal to participate in therapy.
B: Asking the client why they are not participating in therapy may come off as confrontational and could further discourage them from opening up.
D: Encouraging the client to discuss their feelings of hopelessness may be overwhelming for them at this stage and could lead to resistance.
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.