Nokea
A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, and is exhibiting signs of restlessness. Which action should the nurse take first?
- A. Review the heart rhythm on cardiac monitors
- B. Check urinary catheter for obstruction
- C. Auscultate bilateral breath sounds
- D. Give PRN dose of lorazepam (Ativan)
Correct Answer: B
Rationale: When a client in the intensive care unit is mechanically ventilated, has an indwelling urinary catheter, and is restless, the priority action is to check the urinary catheter for obstruction. Restlessness in this context could be due to a blocked catheter causing discomfort or urinary retention, which needs immediate attention to prevent complications. Reviewing the heart rhythm on cardiac monitors can be important but is not the priority in this scenario. Auscultating bilateral breath sounds is also important in a ventilated client but addressing the potential immediate issue of a blocked catheter takes precedence. Giving a PRN dose of lorazepam should not be the first action without addressing the underlying cause of restlessness.
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An older male was recently admitted to the rehabilitation unit with unilateral neglect syndrome as a result of a cerebrovascular accident (CVA). Which action should the nurse include in the plan of care?
- A. Provide additional light in the room to promote sensory stimulation
- B. Teach the client to turn his head from side to side for visual scanning
- C. Place a clock and calendar in the room to improve orientation
- D. Use hand and arm gestures to improve communication and comprehension
Correct Answer: B
Rationale: Teaching the client to turn his head from side to side for visual scanning is essential in addressing unilateral neglect syndrome caused by a cerebrovascular accident. This action helps improve visual awareness and assists the client in overcoming the neglect of one side of the body. Providing additional light for sensory stimulation (Choice A) may not directly address the issue of unilateral neglect. Placing a clock and calendar in the room (Choice C) may be helpful for orientation but does not specifically target unilateral neglect. Using hand and arm gestures for communication (Choice D) may aid in communication but does not directly address the visual scanning deficits associated with unilateral neglect syndrome.
The nurse is measuring the output of an infant admitted for vomiting and diarrhea. During a 12-hour shift, the infant drinks 4 ounces of Pedialyte, vomits 25 ml, and voids twice. The dry diaper weighs 105 grams. Which computer documentation should the nurse enter in the infant's record?
- A. Subtract vomitus from 120 ml Pedialyte, then document 95 ml oral intake.
- B. Compare the difference between the infant's current weight and admission weight.
- C. Document on the flow sheet that the infant voided twice and vomited 25 ml.
- D. Calculate the difference in wet and dry diapers and document 80 ml urine.
Correct Answer: C
Rationale: The correct answer is to document on the flow sheet that the infant voided twice and vomited 25 ml. This choice accurately reflects the need for accurate documentation of intake and output, essential for monitoring the infant's hydration status. Choice A is incorrect because the oral intake should not be calculated by subtracting vomitus from the oral intake. Choice B is incorrect because it does not address the specific documentation related to the infant's output. Choice D is incorrect as it focuses on calculating urine output based on diaper weight, which is not the primary concern in this scenario.
A client who is diagnosed with amyotrophic lateral sclerosis (ALS) is having difficulty swallowing and articulating words. Which intervention is most important to include in this client's plan of care?
- A. Encourage speaking slowly and articulating words
- B. Sit upright and flex chin forward while swallowing
- C. Position a communication board at the bedside
- D. Provide feeding utensils with large grip handles
Correct Answer: B
Rationale: The correct intervention for a client with ALS experiencing difficulty swallowing and articulating words is to sit upright and flex the chin forward while swallowing. This position helps manage dysphagia associated with ALS by facilitating the swallowing process. Encouraging speaking slowly and articulating words (Choice A) may be helpful for speech clarity but does not address the swallowing issue. Positioning a communication board (Choice C) would not directly address the swallowing difficulty. Providing feeding utensils with large grip handles (Choice D) is not the priority intervention for managing dysphagia in ALS.
A female client on the mental health unit tells the nurse that her roommate is sitting on the bathroom floor with superficial cuts on her wrists. The nurse cleans and assesses the client's wrists and asks what happened. She doesn't respond. What should the nurse do next?
- A. Find supplies to put a dressing on the client's wrists
- B. Take the client to a room for supervision by staff
- C. Call the healthcare provider to report the client's behavior
- D. Go find a staff member to stay in the room with the client
Correct Answer: B
Rationale: In this situation, the nurse's priority is to ensure the safety and supervision of the client. Moving the client to a room for direct supervision by staff is crucial to prevent further harm and provide immediate support. While cleaning and assessing the client's wrists are important, ensuring ongoing supervision is vital in this scenario. Calling the healthcare provider to report the behavior may be necessary but is not the immediate action required. Finding supplies to dress the client's wrists is important but not as urgent as ensuring constant supervision by staff.
In developing a plan of care for a client admitted to a mental health unit after attempting suicide by taking a handful of medications, which goal has the highest priority?
- A. Signs a no-self-harm contract
- B. Sleep for at least 6 hours nightly
- C. Attends group therapy every day
- D. Verbalizes a positive self-image
Correct Answer: A
Rationale: The correct answer is A: Signs a no-self-harm contract. Ensuring the client's immediate safety by having them commit to not engaging in self-harm is the highest priority after a suicide attempt. This measure aims to prevent further harm to the client. While sleep, group therapy, and self-image are important aspects of care, they are secondary to ensuring the client's safety in the immediate aftermath of a suicide attempt. Prioritizing the establishment of a no-self-harm contract creates a foundation for addressing other therapeutic goals in the client's care plan.