Nokea
A client is admitted to the hospital with a diagnosis of pneumonia. Which laboratory test result should the nurse monitor to evaluate the client's respiratory function?
- A. Arterial blood gases (ABGs)
- B. Complete blood count (CBC)
- C. Blood glucose levels
- D. Serum electrolyte levels
Correct Answer: A
Rationale: Arterial blood gases (ABGs) are the most appropriate laboratory test to monitor respiratory function in a client with pneumonia. ABGs provide valuable information on oxygenation status, acid-base balance, and how well the lungs are exchanging gases. This information helps in assessing the effectiveness of ventilation and oxygenation, guiding treatment decisions, and evaluating the overall respiratory status of the client.
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What is the most important instruction for the nurse to provide a client with a new colostomy regarding stoma care?
- A. Cleanse the stoma with hydrogen peroxide and water.
- B. Apply a moisture barrier cream to the peristomal skin.
- C. Measure the stoma using a stoma guide.
- D. Use a dry gauze pad to clean the stoma.
Correct Answer: C
Rationale: Measuring the stoma using a stoma guide (C) is crucial as it ensures that the appliance fits properly, which is essential for preventing skin irritation and leakage. Proper measurement helps in selecting the right size of the appliance, promoting comfort and optimal stoma care. In contrast, cleansing with hydrogen peroxide (A), applying a moisture barrier cream (B), and using a dry gauze pad (D) are important but not as critical as ensuring the correct fit of the stoma appliance.
An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care?
- A. Do not massage any reddened areas.
- B. Encourage passive range of motion exercises on extremities.
- C. Position the client laterally, supine, and prone in sequence.
- D. Gently lift the client when moving into a desired position.
Correct Answer: D
Rationale: The essential nursing measure for a client with a fractured left hip on strict bedrest is to gently lift the client when moving into a desired position (D). This helps to avoid shearing forces and prevents further injury. Massaging reddened areas (A) should be avoided to prevent skin damage. Active range of motion exercises (B) may be limited due to pain and muscle spasms in the affected leg. The position described in (C) is contraindicated for a client with a fractured left hip as it may cause additional harm.
The daughter of an older woman who became depressed following the death of her husband asks, 'My mother was always well-adjusted until my father died. Will she tend to be sick from now on?' Which response is best for the nurse to provide?
- A. She is almost sure to be less able to adapt than before.
- B. It's highly likely that she will recover and return to her pre-illness state.
- C. If you can interest her in something besides religion, it will help her stay well.
- D. Cultural strains contribute to each woman's tendencies for recurrences of depression.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is preparing a client for surgery. What action is most important for the nurse to take?
- A. Ensure that the client signs the consent form.
- B. Review the client's allergies with the surgical team.
- C. Confirm the client's identity using two identifiers.
- D. Verify that the surgical site is marked.
Correct Answer: A
Rationale: Ensuring that the client signs the consent form (A) is the most crucial action before surgery. The consent form is legally and ethically necessary for the procedure to proceed. While reviewing allergies (B), confirming identity (C), and verifying the surgical site (D) are essential steps, obtaining the client's informed consent takes precedence to protect the client's rights and ensure a safe surgical experience.
A client is receiving intravenous (IV) fluids postoperatively. Which assessment finding should prompt the nurse to stop the infusion and notify the healthcare provider?
- A. The client reports pain at the IV site
- B. The client's blood pressure is elevated
- C. The client has swelling at the IV site
- D. The client's heart rate is irregular
Correct Answer: C
Rationale: Swelling at the IV site may indicate infiltration or phlebitis, which requires stopping the IV infusion and notifying the healthcare provider. Infiltration occurs when the IV fluid leaks into the surrounding tissue, causing swelling and potential damage. It is crucial to act promptly to prevent further complications and ensure the client's safety.