Nokea
A client arrives at the emergency room with an HR of 120, an RR of 48, and hemoptysis. The nurse should give priority to:
- A. Obtaining a history of the current illness
- B. Applying oxygen via mask
- C. Obtaining additional vital signs
- D. Checking arterial blood gases
Correct Answer: B
Rationale: Hemoptysis and tachypnea suggest respiratory distress, so oxygen administration is the priority to stabilize the client.
You may also like to solve these questions
The physician has ordered insertion of a nasogastric tube to provide supplemental feedings for a client recovering from a stroke. To facilitate insertion of the nasogastric tube, the nurse should:
- A. Offer the client ice chips to swallow as the tube is advanced.
- B. Tell the client to flex his neck on his chest.
- C. Tell the client to hyperextend his neck.
- D. Place the tube in warm water.
Correct Answer: B
Rationale: Flexing the neck aligns the esophagus, facilitating nasogastric tube insertion. Ice chips increase choking risk. Hyperextension misaligns the airway. Warm water is ineffective.
The nurse is caring for a client with possible cervical cancer. What clinical data would the nurse most expect to find in the client's history?
- A. Postcoital vaginal bleeding
- B. Nausea and vomiting
- C. Foul-smelling vaginal discharge
- D. Hyperthermia
Correct Answer: A
Rationale: Postcoital vaginal bleeding is a hallmark symptom of cervical cancer due to tumor involvement of the cervix. Nausea, vomiting, foul-smelling discharge, and hyperthermia may occur in advanced stages or infections but are less specific, so B, C, and D are incorrect.
The nurse is caring for a 10 year-old child who has just been diagnosed with diabetes insipidus. The parents ask about the treatment prescribed, vasopressin. What is priority in teaching the child and family about this drug?
- A. The child should carry a nasal spray for emergency use
- B. The family must observe the child for dehydration
- C. Parents should administer the daily intramuscular injections
- D. The client needs to take daily injections in the short-term
Correct Answer: A
Rationale: Diabetes insipidus results from reduced secretion of the antidiuretic hormone, vasopressin. The child will need to administer daily injections of vasopressin, and should have the nasal spray form of the medication readily available. A medical alert tag should be worn.
A client is scheduled for a cardiac catheterization at 8 AM. The client's laboratory work was completed five days ago. The results were: K⺠3.0 mEq/L, Na⺠148 mEq/L, glucose 178 mg/dL. He complains of muscle weakness and cramps.
Which of the following nursing actions is BEST?
- A. Administer the 7 AM dose of spironolactone (Aldactone).
- B. Encourage eating bananas for breakfast.
- C. Obtain stat K⺠level.
- D. Call for twelve-lead EKG.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) Aldactone is potassium-sparing diuretic and is an oral medication, patient is NPO for procedure (2) is not feasible prior to the cardiac cath because the client is NPO (3) correct-signs and symptoms are indicative of hypokalemia; stat serum K⺠level is needed to confirm the K⺠level prior to going for cardiac catheterization (4) is unnecessary at this time
The nursing team includes two RNs, one LPN/LVN, and one nursing assistant.
- A. Which client is appropriate for the nursing assistant to care for?
- B. A client with Alzheimer’s requiring assistance with feeding.
- C. A client with osteoporosis complaining of burning on urination.
- D. A client with scleroderma receiving a tube feeding.
- E. A client with cancer who has Cheyne-Stokes respirations.
Correct Answer: A
Rationale: Nursing assistants can care for clients with standard, unchanging procedures like feeding an Alzheimer’s patient. Clients with urinary symptoms, tube feedings, or unstable respirations require RN or LPN assessment and intervention.