Nokea
A client is admitted for cellulitis surrounding an insect bite on the lower right arm, and intravenous (IV) antibiotic therapy is prescribed. Which action should the nurse implement before performing venipuncture?
- A. Lower the right arm below the level of the heart.
- B. Elevate the right arm on a pillow.
- C. Apply a tourniquet above the insertion site.
- D. Apply a warm compress to the insertion site.
Correct Answer: A
Rationale: Before performing venipuncture for IV therapy, the nurse should lower the right arm below the level of the heart. Lowering the arm helps dilate the veins, making it easier to locate and access a suitable vein for the procedure. Elevating the arm on a pillow, applying a tourniquet above the insertion site, or applying a warm compress to the insertion site are not appropriate actions before venipuncture as they can affect the venous blood flow and make the procedure more challenging.
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A client with a history of atrial fibrillation is admitted with a new onset of confusion. Which intervention should the nurse implement first?
- A. Obtain a blood glucose level.
- B. Administer an anticoagulant as prescribed.
- C. Perform a neurological assessment.
- D. Administer aspirin as prescribed.
Correct Answer: C
Rationale: Performing a neurological assessment is the priority in this situation as it helps in evaluating the cause of the new onset of confusion in a client with atrial fibrillation. This assessment will provide crucial information about the client's neurological status, which can guide further interventions. Obtaining a blood glucose level (Choice A) is important but should not be the first step when dealing with a new onset of confusion. Administering an anticoagulant (Choice B) or aspirin (Choice D) may be necessary depending on the underlying cause, but assessing the neurological status comes first to determine the appropriate course of action.
A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear results are negative. What information should the nurse include in the client's teaching plan?
- A. Further evaluation involving surgery may be needed
- B. A pelvic exam is also needed before cancer is ruled out
- C. Pap smear evaluation should be continued every six months
- D. One additional negative Pap smear in six months is needed
Correct Answer: A
Rationale: In a 60-year-old female client with a family history of ovarian cancer and an abdominal mass, further evaluation involving surgery may be needed to rule out ovarian cancer. The presence of an abdominal mass raises suspicion for a possible malignancy, and a negative Pap smear result does not rule out ovarian cancer. A pelvic exam alone may not provide sufficient information to confirm or rule out ovarian cancer. Continuing Pap smear evaluations every six months or waiting for one additional negative Pap smear in six months is not appropriate in this scenario, as the abdominal mass requires immediate attention and further evaluation.
A client with a history of rheumatoid arthritis is prescribed methotrexate. Which laboratory value should the nurse monitor closely?
- A. Liver function tests
- B. Complete blood count
- C. Serum creatinine
- D. Prothrombin time
Correct Answer: C
Rationale: Serum creatinine should be closely monitored in a client receiving methotrexate, as the medication can cause nephrotoxicity. Monitoring serum creatinine levels helps assess kidney function and detect potential nephrotoxic effects of methotrexate. Liver function tests (Choice A) are important to monitor for hepatotoxicity caused by methotrexate. While methotrexate can cause bone marrow suppression, leading to anemia, leukopenia, and thrombocytopenia, monitoring a complete blood count (Choice B) is essential but not the priority in this case. Prothrombin time (Choice D) is not typically affected by methotrexate therapy and is not the primary laboratory value to monitor in this situation.
A client with a history of alcoholism is admitted with confusion, ataxia, and nystagmus. Which nursing intervention is a priority for this client?
- A. Monitor for signs of alcohol withdrawal.
- B. Administer thiamine as prescribed.
- C. Provide a quiet environment to reduce confusion.
- D. Initiate fall precautions.
Correct Answer: B
Rationale: The correct answer is B: Administer thiamine as prescribed. Administering thiamine is crucial in clients with a history of alcoholism to prevent Wernicke's encephalopathy, which is characterized by confusion, ataxia, and nystagmus. Monitoring for signs of alcohol withdrawal (choice A) is important but not the priority. Providing a quiet environment (choice C) and initiating fall precautions (choice D) are important interventions, but administering thiamine takes precedence due to the risk of Wernicke's encephalopathy.
A client with a history of diabetes mellitus is admitted with a blood glucose level of 600 mg/dl and is unresponsive. Which intervention should the nurse implement first?
- A. Administer 50% dextrose IV push.
- B. Administer insulin as prescribed.
- C. Monitor the client's urine output.
- D. Obtain a blood glucose level.
Correct Answer: A
Rationale: Administering 50% dextrose IV push is the first priority in treating a blood glucose level of 600 mg/dl in a client who is unresponsive due to hyperglycemia. This intervention is crucial to rapidly raise the client's blood glucose levels and address the emergency situation. Administering insulin (Choice B) would further lower the blood glucose level, worsening the client's condition. Monitoring urine output (Choice C) and obtaining a blood glucose level (Choice D) are important assessments but are secondary to the immediate need to address the high blood glucose levels causing the client's unresponsiveness.