Nokea
A child is admitted with bacterial meningitis. What assessment finding should the nurse monitor most closely?
- A. Monitor the client's skin for rash and lesions.
- B. Monitor for signs of increased intracranial pressure.
- C. Monitor the client's blood pressure closely.
- D. Monitor for changes in heart rate and rhythm.
Correct Answer: B
Rationale: Correct Answer: B. Signs of increased intracranial pressure, such as changes in consciousness or pupil reactivity, are critical to monitor in children with bacterial meningitis to prevent complications. Monitoring the client's skin for rash and lesions (Choice A) is not the priority in bacterial meningitis. While monitoring blood pressure (Choice C) is important, signs of increased intracranial pressure take precedence. Monitoring for changes in heart rate and rhythm (Choice D) is less specific to the condition and may not indicate worsening neurological status.
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A client receiving IV heparin reports tarry stools and abdominal pain. What interventions should the nurse implement?
- A. Prepare to administer warfarin.
- B. Assess the characteristics of the client's pain.
- C. Obtain recent partial thromboplastin time results.
- D. Monitor stool for the presence of blood.
Correct Answer: D
Rationale: The correct intervention for the client receiving IV heparin who reports tarry stools and abdominal pain is to monitor the stool for the presence of blood. This is crucial to assess for gastrointestinal bleeding, a potential complication of heparin therapy. Assessing the characteristics of the client's pain may be helpful but is not the priority when signs of GI bleeding are present. Administering warfarin is not appropriate without a thorough assessment and confirmation of the cause of symptoms. While obtaining recent partial thromboplastin time results is important in monitoring heparin therapy, in this scenario, the immediate concern is to assess for possible GI bleeding.
A client with chronic kidney disease is prescribed a low-sodium diet. What is the nurse's priority teaching?
- A. Choose fresh fruits and vegetables.
- B. Restrict fluid intake to 1500 mL per day.
- C. Limit sodium intake to 2 grams per day.
- D. Increase potassium intake to prevent hypokalemia.
Correct Answer: C
Rationale: The correct answer is C: 'Limit sodium intake to 2 grams per day.' For a client with chronic kidney disease, limiting sodium intake is crucial because it helps prevent fluid retention and reduces the workload on the kidneys. Choice A, 'Choose fresh fruits and vegetables,' is generally a healthy dietary recommendation but not the priority when focusing on a low-sodium diet. Choice B, 'Restrict fluid intake to 1500 mL per day,' is important but secondary to limiting sodium intake. Choice D, 'Increase potassium intake to prevent hypokalemia,' is not the priority teaching for a client with chronic kidney disease on a low-sodium diet.
The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective and must be reported by the nurse immediately to the healthcare provider?
- A. Nausea and vomiting
- B. Fever of 103 degrees Fahrenheit (39.5 degrees Celsius)
- C. Diffuse macular rash
- D. Muscle tenderness
Correct Answer: B
Rationale: A fever of 103 degrees Fahrenheit indicates that the infection is not under control despite antibiotic therapy. Fever is a common sign of ongoing infection or inadequate response to treatment. Nausea and vomiting, diffuse macular rash, and muscle tenderness are not typically indicative of the effectiveness of antibiotic therapy in treating infective endocarditis.
A client presents with a suspected infection and has a fever of 102°F. What is the nurse's immediate priority?
- A. Administer antipyretics as ordered
- B. Take a blood culture before administering antibiotics
- C. Encourage fluid intake to prevent dehydration
- D. Monitor vital signs every hour
Correct Answer: B
Rationale: The immediate priority for a client with a suspected infection and fever is to take a blood culture before administering antibiotics. This step is crucial to identify the causative organism and ensure appropriate treatment. Administering antipyretics or encouraging fluid intake are important but should come after obtaining the blood culture to avoid interfering with test results. Monitoring vital signs, although essential, is not the immediate priority compared to identifying the infectious agent.
A client with acute pancreatitis is receiving nothing by mouth (NPO) status. What is the nurse's priority intervention?
- A. Administer antiemetic medication as prescribed.
- B. Monitor the client's intake and output.
- C. Provide mouth care to keep the client comfortable.
- D. Elevate the client's head of the bed.
Correct Answer: B
Rationale: The correct answer is B: Monitor the client's intake and output. When a client with acute pancreatitis is on NPO status, the nurse's priority intervention is to monitor the client's intake and output. This is crucial to assess for signs of dehydration, electrolyte imbalances, and to ensure the client is responding appropriately to treatment. Administering antiemetic medication (choice A) may be necessary for managing nausea and vomiting but is not the priority over monitoring intake and output. Providing mouth care (choice C) and elevating the client's head of the bed (choice D) are important aspects of care but do not take precedence over monitoring intake and output to prevent complications in clients with NPO status due to acute pancreatitis.