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 38-year-old male client collapsed at his outside construction job in Texas in July. His admitting vital signs to ICU are, BP 82/70, heart rate 140 beats/minute, urine output 10 ml/hr, skin cool to the touch. Pulmonary artery (PA) pressures are, PAWP 1, PAP 8/2, RAP -1, SVR 1600. What nursing action has the highest priority?
- A. Apply a hypothermia unit to stabilize core temperature.
- B. Increase the client's IV fluid rate to 200 ml/hr.
- C. Call the hospital chaplain to counsel the family.
- D. Draw blood cultures x3 to detect infection.
Correct Answer: B
Rationale: The correct answer is B: Increase the client's IV fluid rate to 200 ml/hr. The client's vital signs indicate hypotension, tachycardia, decreased urine output, and cool skin, suggesting hypovolemic shock. Increasing IV fluid rate will help to restore intravascular volume and improve perfusion to vital organs. This is the highest priority as it addresses the immediate physiological need for circulatory support.
Choice A is incorrect because hypothermia is not indicated based on the client's presentation. Choice C is incorrect as it does not address the client's urgent physiological needs. Choice D is incorrect as drawing blood cultures, while important, is not the most immediate priority in this situation.
Because the census is currently low in the Obstetrics (OB) unit, one of the nurses is sent to work on a medical-surgical unit for the day, or until the OB unit becomes busy. Which client assessment is best for the charge nurse to assign to the OB nurse?
- A. An adult who had a colon resection yesterday and has an IV.
- B. An older adult who has a fever of unknown origin.
- C. A woman who had an acute brain attack (stroke, CVA) 6 hours ago.
- D. A teenager with a femoral fracture who is in traction.
Correct Answer: A
Rationale: The correct answer is A because the OB nurse's background in obstetrics makes them most suitable to care for a post-operative patient with an IV. This assignment aligns with the nurse's skill set and ensures safe and competent care. Choices B, C, and D involve medical-surgical conditions that may require specialized knowledge and skills beyond the OB nurse's expertise, potentially compromising patient care. Assigning the OB nurse to care for a post-operative patient with an IV is the most appropriate choice given the circumstances.
During an admission physical assessment, the nurse is examining a newborn who is small for gestational age (SGA). Which finding should the nurse report immediately to the pediatric healthcare provider?
- A. Heel stick glucose of 65 mg/dL.
- B. Head circumference of 35 cm (14 inches).
- C. Widened, tense, bulging fontanel.
- D. High-pitched shrill cry.
Correct Answer: C
Rationale: The correct answer is C: Widened, tense, bulging fontanel. This finding is concerning as it can indicate increased intracranial pressure, potentially leading to serious complications in a newborn. The fontanel should be flat or slightly depressed, not bulging. Immediate reporting is necessary for timely intervention.
Incorrect choices:
A: Heel stick glucose of 65 mg/dL is slightly low but not an immediate concern; can be managed with feeding.
B: Head circumference of 35 cm is within the normal range for a newborn and does not require immediate action.
D: High-pitched shrill cry can be a sign of distress but not as urgent as a bulging fontanel in this context.
A client with a severe head injury is admitted to the intensive care unit (ICU). Which finding should the nurse report to the healthcare provider immediately?
- A. Urine output of 100 mL/hour.
- B. Intracranial pressure (ICP) of 20 mm Hg.
- C. Respiratory rate of 12 breaths/minute.
- D. Mean arterial pressure (MAP) of 70 mm Hg.
Correct Answer: B
Rationale: The correct answer is B: Intracranial pressure (ICP) of 20 mm Hg. Elevated ICP can lead to increased intracranial pressure, which can further damage brain tissue and impair cerebral perfusion. This is a critical finding that requires immediate intervention to prevent further brain damage.
A: Urine output of 100 mL/hour is within the normal range and does not pose an immediate threat to the client's condition.
C: Respiratory rate of 12 breaths/minute is within normal limits and does not indicate an immediate concern.
D: Mean arterial pressure (MAP) of 70 mm Hg is within the normal range for most adults and does not require immediate intervention in this scenario.
A client with a history of diabetes mellitus is admitted with a foot ulcer. The nurse should recognize that which intervention is most critical in promoting healing of the foot ulcer?
- A. Strict control of blood glucose levels.
- B. Regular dressing changes with sterile technique.
- C. Application of antibiotic ointment.
- D. Hydrotherapy treatment daily.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Strict control of blood glucose levels is critical in promoting healing of foot ulcers in diabetic patients.
2. High blood glucose levels can impair wound healing by affecting circulation and immune response.
3. Maintaining normal glucose levels helps optimize tissue repair and prevent further complications.
4. Regular dressing changes (B) are important but not as critical as controlling blood glucose levels.
5. Application of antibiotic ointment (C) may be necessary for infected ulcers, but not the most critical intervention.
6. Hydrotherapy treatment (D) can help with wound cleansing, but it is not as essential as controlling blood glucose levels.