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A client being mechanically ventilated after experiencing a fat embolus is visibly anxious. Which action should the nurse take?
- A. Remain with the client and provide reassurance.
- B. Ask a family member to stay with the client at all times.
- C. Encourage the client to sleep until arterial blood gas results improve.
- D. Ask the primary health care provider to write a prescription for an antianxiety medication.
Correct Answer: A
Rationale: The nurse always speaks to the client calmly and provides reassurance to the anxious client. Family members are also stressed because of the severity of the situation; therefore, it is not beneficial to ask the family to take on the burden of remaining with the client at all times. Encouraging the client to sleep will not assist in relieving the client's anxiety. Antianxiety medications are used only if necessary and if other interventions fail to relieve the client's anxiety.
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A client with a history of chronic lymphocytic leukemia is prescribed prednisone. The nurse should monitor the client for which of the following side effects?
- A. Hypoglycemia.
- B. Weight gain.
- C. Hypotension.
- D. Hair loss.
Correct Answer: B
Rationale: Prednisone, a corticosteroid, commonly causes weight gain due to fluid retention and increased appetite.
Which of the following is a nursing diagnosis that reflects some unexpected response to a therapy?
- A. Episiotomy extension related to a forceps delivery
- B. Respiratory depression related to NSAIDs
- C. Hemothorax related to a latex allergy
- D. All of the above
Correct Answer: D
Rationale: All listed diagnoses reflect unexpected responses to therapies (forceps delivery, NSAIDs, latex exposure), qualifying as adverse reactions.
The nurse is caring for a client with a history of burns covering 25% of the body. Which of the following interventions should be included in the plan of care? Select all that apply.
- A. Monitor for signs of infection.
- B. Administer I.V. fluids as prescribed.
- C. Apply silver sulfadiazine to burns.
- D. Provide a low-protein diet.
- E. Administer analgesics as needed.
Correct Answer: A, B, C, E
Rationale: Monitoring for infection, I.V. fluids, silver sulfadiazine, and analgesics are essential for burn care. A high-protein diet is needed, not low-protein.
A client with a history of type 2 diabetes mellitus is prescribed sitagliptin (Januvia). The nurse should monitor the client for which of the following side effects?
- A. Hypoglycemia.
- B. Pancreatitis.
- C. Hypertension.
- D. Weight gain.
Correct Answer: B
Rationale: Sitagliptin can cause pancreatitis, a serious side effect requiring monitoring for symptoms like abdominal pain.
The nurse is assessing home care needs for a group of clients. Which clients qualify for home care services? The client who? Select all that apply.
- A. Requires monitoring of prothrombin time due to Coumadin (warfarin) therapy.
- B. Has episodes of vertigo that result in falls.
- C. Has multiple sclerosis with an open, draining lesion on a foot.
- D. Needs stronger lenses for glasses.
Correct Answer: A,B,C
Rationale: Clients requiring prothrombin time monitoring, those with vertigo causing falls, and those with open lesions qualify for home care due to medical needs. Needing glasses does not typically require skilled home care services.