Nokea
A client is admitted to the psychiatric unit after lavage and stabilization in the emergency room for an overdose of antidepressants. This is her third attempt in 2 years. The highest priority intervention at this time is to:
- A. Assess level of consciousness
- B. Assess suicide potential
- C. Observe for sedation and hypotension
- D. Orient to her room and unit rules
Correct Answer: B
Rationale: Suicide assessment is always appropriate for clients with a history of previous attempts or depression, because either of these factors places the client at high risk.
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In performing the initial nursing assessment on a client at the prenatal clinic, the nurse will know that which of the following alterations is abnormal during pregnancy?
- A. Striae gravidarum
- B. Chloasma
- C. Dysuria
- D. Colostrum
Correct Answer: C
Rationale: Dysuria is abnormal and may indicate a urinary tract infection, unlike the other options, which are normal pregnancy changes.
A 70-year-old client is almost finished receiving her second unit of packed red blood cells. The client, who weighs 80 lb, has started complaining of being short of breath and now has crackles in the bases of her lungs. After slowing or stopping the transfusion, the most appropriate initial nursing action would be to:
- A. Raise the client's head and place her feet in a dependent position
- B. Notify the physician
- C. Place the client on 2 liters of O2 via nasal cannula
- D. Administer furosemide (Lasix) 20 mg IV push
Correct Answer: A
Rationale: Raising the head and placing feet in a dependent position reduces venous return and pulmonary congestion, addressing transfusion-related circulatory overload.
Which client clinical manifestation during a bone marrow transplantation procedure alerts the nurse to the possibility of an adverse reaction?
- A. Fever
- B. Red colored urine
- C. Hypertension
- D. Shortness of breath
Correct Answer: D
Rationale: Shortness of breath may indicate an acute transfusion reaction (e.g., TRALI) during bone marrow transplantation, requiring immediate action. Fever (A), red urine (B), and hypertension (C) are less specific or expected.
The client is admitted with a diagnosis of acute leukemia. Which nursing intervention is the priority?
- A. Administering pain medication
- B. Preventing infection
- C. Monitoring blood glucose levels
- D. Encouraging high-fiber foods
Correct Answer: B
Rationale: Acute leukemia causes immunosuppression, making infection prevention (e.g., hand hygiene, protective isolation) the priority to avoid life-threatening complications. Pain, glucose, and diet are secondary.
The nurse caring for a client with a closed head injury obtains an intracranial pressure (ICP) reading of 17 mmHg. The nurse recognizes that:
- A. The ICP is elevated and the doctor should be notified.
- B. The ICP is normal; therefore, no further action is needed.
- C. The ICP is low and the client needs additional IV fluids.
- D. The ICP reading is not as reliable as the Glasgow coma scale.
Correct Answer: A
Rationale: Normal ICP is 5-15 mmHg. A reading of 17 mmHg is elevated, indicating potential brain swelling, and requires immediate notification of the physician. The Glasgow scale complements but does not replace ICP monitoring.