Nokea
A caregiver is caring for a 5-month-old infant who has manifestations of severe dehydration and a prescription for parenteral fluid therapy. The caregiver asks, 'What are the indications that my baby needs an IV?' Which of the following responses should the caregiver make?
- A. Your baby needs an IV because she is not producing any tears
- B. Your baby needs an IV because her fontanels are bulging
- C. Your baby needs an IV because she is breathing slower than normal
- D. Your baby needs an IV because her heart rate is decreasing
Correct Answer: A
Rationale: The correct response is A: 'Your baby needs an IV because she is not producing any tears.' In infants, the inability to produce tears is a sign of severe dehydration. This is a crucial indication for the need for intravenous (IV) fluid therapy to rehydrate the infant. While the other options may also be symptoms of dehydration, the absence of tears is a more direct and specific indicator requiring immediate attention and intervention.
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A client has unilateral paralysis and dysphagia following a right hemispheric stroke. Which of the following interventions should the nurse include in the plan?
- A. Place the client's left arm on a pillow while he is sitting.
- B. Provide total care in assisting with the client's ADLs.
- C. Encourage mobility and avoid bed rest.
- D. Facilitate feeding by placing food on the left side of the client's mouth when ready to eat.
Correct Answer: A
Rationale: Placing the client's left arm on a pillow while sitting helps prevent shoulder displacement and assists in maintaining proper positioning and alignment. This intervention is crucial to prevent complications associated with immobility. Providing total care in ADLs may hinder the client's independence and recovery. Encouraging mobility is essential in preventing complications of immobility. Facilitating feeding by placing food on the unaffected side of the mouth helps reduce the risk of aspiration in clients with dysphagia.
A client who wears glasses is under the care of a nurse. Which of the following actions should the nurse take?
- A. Store the glasses in a labeled case.
- B. Clean the glasses with hot water
- C. Clean the glasses with a paper towel.
- D. Store the glasses on the bedside table.
Correct Answer: A
Rationale: It is essential for the nurse to store the client's glasses in a labeled case to ensure they are kept safe and protected from damage. Storing them in a case helps prevent scratches, breakage, or misplacement. This practice promotes proper eyewear hygiene and ensures the client has their glasses readily available when needed. Cleaning the glasses with hot water or a paper towel can potentially damage the lenses or frames. Storing the glasses on the bedside table increases the risk of misplacement or damage.
A client has had a cast applied, and a nurse is providing care. Which of the following actions should the nurse take first?
- A. Place an ice pack over the cast.
- B. Palpate the pulse distal to the cast.
- C. Teach the client to keep the cast clean and dry.
- D. Position the casted extremity on a pillow.
Correct Answer: B
Rationale: When caring for a client with a newly applied cast, the nurse's priority should be to assess the circulation by palpating the pulse distal to the cast. This is crucial to ensure there is no compromise in blood flow, which could lead to serious complications. Placing an ice pack over the cast, teaching the client about cast care, and positioning the casted extremity on a pillow are important interventions but should follow the assessment of circulation.
A healthcare provider is assessing a client who has left-sided heart failure. Which of the following should the healthcare provider identify as a manifestation of pulmonary congestion?
- A. Frothy, pink sputum
- B. Jugular vein distention
- C. Weight gain
- D. Bradypnea
Correct Answer: A
Rationale: Pulmonary congestion is a common manifestation of left-sided heart failure. When the left side of the heart fails, blood backs up into the lungs, leading to pulmonary congestion. This can result in symptoms such as frothy, pink-tinged sputum due to the presence of blood in the respiratory secretions. Jugular vein distention, weight gain, and bradypnea are also associated with heart failure, but frothy, pink sputum specifically indicates pulmonary congestion in this scenario.
When a client is comatose and has advance directives stating a desire to avoid life-sustaining measures, but the family wants these measures, what action should the nurse take?
- A. Arrange for an ethics committee meeting to address the family's concerns.
- B. Support the family's decision and initiate life-sustaining measures.
- C. Complete an incident report.
- D. Encourage the family to contact an attorney.
Correct Answer: A
Rationale: In this scenario, the nurse should prioritize the client's wishes as outlined in the advance directives. By arranging for an ethics committee meeting, the nurse can facilitate discussions between the family and healthcare team to ensure that the client's wishes are respected while addressing the concerns of the family. This approach promotes ethical decision-making and collaborative communication among all involved parties, ultimately aiming to provide the best possible care for the client while considering their autonomy and preferences.