Nokea
A client is admitted to the hospital with a diagnosis of septic shock. Which assessment finding indicates that the client's condition is deteriorating?
- A. Heart rate of 110 beats per minute
- B. Temperature of 99.5°F (37.5°C)
- C. Blood pressure of 88/52 mmHg
- D. Respiratory rate of 24 breaths per minute
Correct Answer: C
Rationale: A blood pressure of 88/52 mmHg indicates hypotension, which is a sign of worsening septic shock. Hypotension can lead to organ failure and requires immediate intervention. Elevated heart rate (choice A), mild fever (choice B), and slightly increased respiratory rate (choice D) are common in septic shock and may not necessarily indicate a deteriorating condition as much as hypotension does.
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A client with acute pancreatitis is receiving nothing by mouth (NPO) status. What is the nurse's priority intervention?
- A. Administer antiemetic medication as prescribed.
- B. Monitor the client's intake and output.
- C. Provide mouth care to keep the client comfortable.
- D. Elevate the client's head of the bed.
Correct Answer: B
Rationale: The correct answer is B: Monitor the client's intake and output. When a client with acute pancreatitis is on NPO status, the nurse's priority intervention is to monitor the client's intake and output. This is crucial to assess for signs of dehydration, electrolyte imbalances, and to ensure the client is responding appropriately to treatment. Administering antiemetic medication (choice A) may be necessary for managing nausea and vomiting but is not the priority over monitoring intake and output. Providing mouth care (choice C) and elevating the client's head of the bed (choice D) are important aspects of care but do not take precedence over monitoring intake and output to prevent complications in clients with NPO status due to acute pancreatitis.
A client with type 1 diabetes is admitted to the emergency room with abdominal pain, polyuria, and confusion. What should the nurse implement first?
- A. Administer intravenous insulin.
- B. Start an intravenous fluid bolus.
- C. Obtain a blood glucose level.
- D. Administer an antiemetic.
Correct Answer: B
Rationale: In this scenario, the nurse should first start an intravenous fluid bolus. This intervention is crucial in addressing severe dehydration associated with diabetic ketoacidosis, a life-threatening complication of type 1 diabetes. Administering intravenous insulin (Choice A) is important but should follow fluid resuscitation. Obtaining a blood glucose level (Choice C) is necessary but not as urgent as addressing the dehydration. Administering an antiemetic (Choice D) is not the priority in this situation.
A client has burns covering 40% of their total body surface area (TBSA). What is the nurse's priority action?
- A. Monitor the client's urinary output hourly.
- B. Apply cool, moist dressings to the burned areas.
- C. Administer pain medication to reduce discomfort.
- D. Administer IV fluids to prevent hypovolemia.
Correct Answer: A
Rationale: The correct answer is A: Monitor the client's urinary output hourly. Clients with burns covering a large percentage of their total body surface area are at high risk for hypovolemia due to fluid loss. Monitoring urinary output is crucial because it helps assess kidney function and fluid balance, providing essential information about the client's hemodynamic status. Applying cool, moist dressings (choice B) is important but not the priority over assessing fluid balance. Administering pain medication (choice C) is essential for comfort but not the priority over monitoring for potential complications like hypovolemia. Administering IV fluids (choice D) is important to prevent hypovolemia, but monitoring urinary output should be the priority to guide fluid resuscitation.
A client with deep vein thrombosis (DVT) is prescribed warfarin. What teaching should the nurse provide?
- A. Avoid foods high in vitamin K, such as spinach.
- B. Report any signs of bleeding, such as bruising or nosebleeds.
- C. Take the medication on an empty stomach.
- D. Monitor for changes in blood pressure.
Correct Answer: B
Rationale: The correct teaching for a client prescribed warfarin is to report any signs of bleeding, such as unusual bruising, nosebleeds, or blood in the urine or stool. Warfarin is an anticoagulant that increases the risk of bleeding, so it is crucial for the client to promptly report any bleeding-related symptoms for evaluation by a healthcare provider. Choices A, C, and D are incorrect. Avoiding foods high in vitamin K, such as spinach, is more relevant for clients taking warfarin to maintain consistent vitamin K intake. Warfarin should be taken with food to avoid gastrointestinal upset, so taking it on an empty stomach is not recommended. Monitoring for changes in blood pressure is not directly related to warfarin therapy; instead, the focus should be on monitoring for signs of bleeding.
A pregnant client complains of heartburn. What instruction should the nurse provide?
- A. Eat spicy food to help digestion.
- B. Eat small meals throughout the day to avoid a full stomach.
- C. Drink carbonated beverages to ease digestion.
- D. Avoid drinking fluids after meals.
Correct Answer: B
Rationale: The correct instruction for a pregnant client experiencing heartburn is to eat small meals throughout the day to avoid a full stomach. This helps prevent the stomach from becoming overly full, reducing the likelihood of heartburn during pregnancy. Choices A, C, and D are incorrect. Eating spicy food can exacerbate heartburn, carbonated beverages may trigger heartburn due to gas, and avoiding fluids after meals does not directly address the issue of heartburn.