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A client is admitted with a diagnosis of diabetic ketoacidosis (DKA). Which assessment finding should the nurse anticipate?
- A. Oliguria.
- B. Kussmaul respirations.
- C. Fruity odor on the breath.
- D. Blood glucose level of 250 mg/dL.
Correct Answer: B
Rationale: Kussmaul respirations (B) are a deep and labored breathing pattern associated with diabetic ketoacidosis (DKA) and are expected in this condition. While oliguria (A), fruity odor on the breath (C), and elevated blood glucose level (D) are also signs of DKA, Kussmaul respirations are more specific and critical to the condition, indicating severe metabolic acidosis.
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What is the most important action for the nurse to take when caring for a client with a spinal cord injury experiencing autonomic dysreflexia?
- A. Elevate the head of the bed to 45 degrees.
- B. Monitor the client's respiratory rate.
- C. Administer an antihypertensive medication.
- D. Assess the client's blood glucose level.
Correct Answer: A
Rationale: In a client with autonomic dysreflexia, the most critical action is to elevate the head of the bed to 45 degrees (A). This positioning helps reduce blood pressure, which is essential in managing autonomic dysreflexia. Monitoring the client's respiratory rate (B) is important for overall assessment but not the priority in this situation. Administering an antihypertensive medication (C) without addressing the positioning issue first can lead to further complications. Assessing the client's blood glucose level (D) is not directly related to autonomic dysreflexia and is not the initial priority in this scenario.
While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. What action should the nurse take in response to this finding?
- A. Complete the intermittent suction of the nasopharynx.
- B. Reposition the pulse oximeter clip to obtain a new reading.
- C. Stop suctioning until the pulse oximeter reading is above 95%.
- D. Apply an oxygen mask over the client's nose and mouth.
Correct Answer: A
Rationale: A stable oxygen saturation reading of 94% indicates that the nurse can continue with the suctioning procedure. It is within an acceptable range, and there is no immediate need to interrupt the procedure. Continuing with the suctioning will help maintain airway patency and promote adequate oxygenation. Choice B is incorrect because repositioning the pulse oximeter clip is unnecessary when the reading is stable. Choice C is incorrect as there is no evidence to support stopping the suctioning procedure solely based on the oxygen saturation reading of 94%. Choice D is not the best action at this point, as applying an oxygen mask is not indicated when the oxygen saturation is stable and within an acceptable range.
The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction?
- A. Perform range-of-motion exercises to prevent contractures.
- B. Decrease the client's fluid intake to prevent diarrhea.
- C. Massage the client's legs to reduce the occurrence of embolisms.
- D. Turn the client from side to back every shift.
Correct Answer: A
Rationale: Performing range-of-motion exercises is essential in preventing contractures, which are common complications of immobility. These exercises help maintain joint flexibility and muscle strength, reducing the risk of contractures that can lead to functional limitations or pain for the client. Choices B, C, and D are incorrect. Decreasing fluid intake does not prevent immobility complications, but it can lead to dehydration. Massaging the client's legs does not directly address the prevention of immobility complications like contractures. Turning the client from side to back every shift is important for preventing pressure ulcers but does not directly address complications of immobility like contractures.
The nurse is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the nurse should further assess the medication order?
- A. At home I take my pills at 8:00 am.
- B. It costs a lot of money to buy all of these pills.
- C. I get so tired of taking pills every day.
- D. This is a new pill I have never taken before.
Correct Answer: D
Rationale: The client's statement that 'This is a new pill I have never taken before' indicates the need for further assessment by the nurse to ensure the medication is correct and safe. Choices A, B, and C do not raise immediate concerns about the medication order; therefore, they are incorrect. Choice A simply provides information about the client's usual medication schedule, choice B is related to the cost of the pills, and choice C expresses fatigue from taking pills, but none of these statements suggest a potential issue with the new medication.
You are assigned to teach a student how to suction an adult patient with a tracheostomy. Which of the following actions by the student would be incorrect?
- A. Pre-oxygenating the patient with a Resuscibag at 100% O2 several times before suctioning.
- B. Maintaining wall suction pressure at 110-150 mmHg.
- C. Not suctioning for greater than 10-15 seconds at a time.
- D. Applying gentle intermittent pressure and rotating the catheter during the insertion phase of suctioning.
Correct Answer: D
Rationale: The incorrect action by the student is applying gentle intermittent pressure and rotating the catheter during the insertion phase of suctioning. This technique can cause trauma to the tracheal walls, increasing the risk of injury to the patient. It is essential to perform suctioning gently and without rotation to prevent complications in patients with a tracheostomy. Pre-oxygenating the patient, maintaining appropriate suction pressure, and limiting suctioning time are all correct actions when suctioning a patient with a tracheostomy.