Nokea
A client is admitted with suspected meningitis. Which assessment finding requires immediate intervention?
- A. Headache.
- B. Fever.
- C. Nuchal rigidity.
- D. Seizures.
Correct Answer: D
Rationale: The correct answer is D: Seizures. Seizures in a patient with suspected meningitis indicate increased intracranial pressure, which is a medical emergency requiring immediate intervention to prevent brain damage or herniation. Headache (A), fever (B), and nuchal rigidity (C) are common symptoms of meningitis but do not pose an immediate threat to life like seizures do. Addressing the seizures first is crucial to prevent further complications and ensure the patient's safety.
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A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. Which intervention should the nurse implement to ensure the client's safety?
- A. Increase the oxygen flow rate to 6 liters/minute if the client is short of breath.
- B. Instruct the client to breathe deeply and cough frequently.
- C. Use a nasal cannula to deliver oxygen at a low flow rate.
- D. Encourage the client to remove the oxygen when eating or drinking.
Correct Answer: C
Rationale: The correct answer is C because using a nasal cannula to deliver oxygen at a low flow rate is the safest intervention for a client with COPD. High flow rates can suppress the client's respiratory drive, leading to hypoventilation. Choice A is incorrect because increasing oxygen flow rate without assessing the client's oxygen saturation can be harmful. Choice B is incorrect as deep breathing and coughing can increase oxygen demand and worsen respiratory distress. Choice D is incorrect because oxygen should not be removed during eating or drinking, as it is essential for tissue oxygenation.
A client who delivered a 7-pound infant 12 hours ago is complaining of a severe headache. The client's blood pressure is 110/70, respiratory rate is 18 breaths/minute, heart rate is 74 beats/minute, and temperature is 98.6º F. The client's fundus is firm and one fingerbreadth above the umbilicus. What action should the healthcare team implement first?
- A. Notify the healthcare provider of the assessment findings.
- B. Determine if the client received anesthesia during delivery.
- C. Assign a licensed nurse to reassess the client's vital signs.
- D. Obtain a STAT hemoglobin and hematocrit.
Correct Answer: B
Rationale: The correct answer is B because the client delivered a 7-pound infant 12 hours ago and is now experiencing a severe headache, which could indicate postpartum preeclampsia. Checking if the client received anesthesia during delivery is crucial as certain types of anesthesia can increase the risk of postpartum preeclampsia. This step is important to determine if anesthesia is a contributing factor to the client's symptoms.
Option A is incorrect because immediate action is needed to address the client's symptoms related to anesthesia. Option C is incorrect as reassessing vital signs alone may not provide information specific to the client's headache. Option D is incorrect as obtaining a hemoglobin and hematocrit would not directly address the client's headache or potential anesthesia-related issues.
A male client in the day room becomes increasingly angry and aggressive when denied a day-pass. Which action should the nurse implement?
- A. Tell him he can have a day pass if he calms down.
- B. Put the client's behavior on extinction.
- C. Decrease the volume on the television set.
- D. Instruct the client to sit down and be quiet.
Correct Answer: D
Rationale: The correct answer is D because instructing the client to sit down and be quiet is a non-confrontational and calming approach to de-escalate the situation. It helps redirect the client's focus and encourages self-regulation. Choice A may reinforce the aggressive behavior by rewarding it. Choice B (putting behavior on extinction) may escalate the situation further. Choice C (decreasing TV volume) does not address the client's behavior directly.
A healthcare provider is preparing to administer a scheduled dose of intravenous (IV) metoprolol (Lopressor) to a client. The client's apical pulse is 58 beats/minute. What action should the healthcare provider take?
- A. Administer the medication as prescribed.
- B. Hold the medication and notify the healthcare provider.
- C. Give half the prescribed dose and recheck the pulse in 30 minutes.
- D. Administer the medication and then recheck the pulse in 30 minutes.
Correct Answer: B
Rationale: The correct answer is B: Hold the medication and notify the healthcare provider. The rationale is that metoprolol is a beta-blocker that can further decrease heart rate. With a low apical pulse of 58 beats/minute, administering metoprolol can potentially cause bradycardia or further slow down the heart rate to dangerous levels. Holding the medication and notifying the healthcare provider allows for further assessment and potential adjustment of the dosage or consideration of alternative treatments.
Incorrect choices:
A: Administering the medication as prescribed can lead to bradycardia and potential harm to the client.
C: Giving half the prescribed dose and rechecking the pulse in 30 minutes can still lead to further bradycardia and potential harm.
D: Administering the medication and then rechecking the pulse in 30 minutes is not appropriate as the initial pulse rate is already low, and waiting to recheck could lead to adverse effects before intervention.
When a client reports being allergic to penicillin, which question should the nurse ask to gather more information?
- A. Are you allergic to any other medications?
- B. How often have you taken penicillin in the past?
- C. Is anyone else in your family allergic to penicillin?
- D. What happens to you when you take penicillin?
Correct Answer: D
Rationale: Rationale: Option D is the correct answer because it directly addresses the client's experience with penicillin, providing crucial details about the allergic reaction. By asking what happens when the client takes penicillin, the nurse gains specific information to assess the severity and type of allergic reaction. This helps in determining appropriate interventions and alternative medications. Options A, B, and C are incorrect as they do not focus on gathering detailed information about the client's allergic reaction to penicillin. Option A is too broad, option B is not relevant to the current situation, and option C does not directly address the client's individual experience.