Nokea
A client is receiving an IV infusion of an antibiotic. The client calls the nurse feeling uneasy due to congestion. Which action by the nurse is most appropriate?
- A. Elevate the head of the client's bed to 45 degrees
- B. Have another nurse call the Rapid Response Team
- C. Prepare to administer diphenhydramine (Benadryl)
- D. Slow the rate of the IV infusion
Correct Answer: B
Rationale: In this situation, the client's symptoms of congestion and feeling uneasy may indicate an anaphylactic reaction, which can be life-threatening. The most appropriate action is to call the Rapid Response Team to provide immediate assistance and interventions. Elevating the head of the bed, administering diphenhydramine, or slowing the IV infusion rate are not the priority actions in the case of a potential severe allergic reaction. These interventions may delay necessary emergency care and potentially worsen the client's condition.
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A client who has a head injury is transported to the emergency department. Which assessment does the emergency department nurse perform immediately?
- A. Pupil response
- B. Motor function
- C. Respiratory status
- D. Short-term memory
Correct Answer: C
Rationale: In a client with a head injury, assessing the respiratory status is the priority as airway and breathing are essential for life. Immediate attention to respiratory status is crucial to ensure adequate oxygenation. While assessing pupil response and motor function are also important in head injuries, ensuring the client's ability to breathe takes precedence. Short-term memory assessment is not a priority in the emergent phase of care for a client with a head injury.
When obtaining a client's vital signs, the nurse assesses a blood pressure of 134/88 mm Hg. What is the nurse's best intervention?
- A. Call the healthcare provider and report the finding.
- B. Reassess the client's blood pressure at the next follow-up appointment.
- C. Administer an additional antihypertensive medication to the client.
- D. Teach the client lifestyle modifications to decrease blood pressure.
Correct Answer: D
Rationale: The correct answer is to teach the client lifestyle modifications to decrease blood pressure. A blood pressure reading of 134/88 mm Hg falls within the prehypertension range. The initial approach to managing prehypertension involves lifestyle modifications such as dietary changes, exercise, and stress reduction techniques. Calling the healthcare provider without attempting non-pharmacological interventions first is premature. Reassessing blood pressure at the next follow-up appointment may delay necessary interventions. Administering additional antihypertensive medication is not indicated at this stage as lifestyle modifications are the first line of treatment for prehypertension.
The nurse is assessing a client with a history of heart failure who is receiving a unit of packed red blood cells. The client's respiratory rate is 33 breaths/min and blood pressure is 140/90 mm Hg. Which action does the nurse take first?
- A. Administer prescribed diphenhydramine (Benadryl).
- B. Continue to monitor the client's vital signs.
- C. Stop the infusion of packed red blood cells.
- D. Slow the infusion rate of the transfusion
Correct Answer: D
Rationale: In this scenario, the client is showing signs of a potential transfusion reaction, indicated by an increased respiratory rate. The nurse's initial action should be to slow down the infusion rate of the packed red blood cells to prevent further complications. Administering diphenhydramine or stopping the infusion should not be the first actions taken, as the priority is to ensure the client's safety and prevent adverse reactions. Continuing to monitor vital signs without taking immediate action to address the increased respiratory rate would delay appropriate intervention.
A client is diagnosed with varicella (chickenpox). The nurse places the client on which precautions?
- A. Airborne
- B. Standard
- C. Contact
- D. Droplet
Correct Answer: A
Rationale: The correct answer is 'Airborne.' Varicella (chickenpox) is caused by the varicella-zoster virus, which spreads through the air by respiratory droplets. Therefore, placing the client on airborne precautions is necessary to prevent the transmission of the virus. Choice B, 'Standard precautions,' involve basic infection prevention measures that are used for all client care. Choice C, 'Contact precautions,' are used for diseases that spread by direct or indirect contact. Choice D, 'Droplet precautions,' are implemented for diseases transmitted by respiratory droplets that are larger than 5 microns.
The healthcare professional is assessing a client with hypertension. Which client outcome is indicative of effective hypertension management?
- A. Absence of pedal edema in the lower legs.
- B. Absence of complaints of sexual dysfunction.
- C. No indication of renal impairment.
- D. Blood pressure reading of 148/94 mm Hg.
Correct Answer: C
Rationale: The correct answer is 'No indication of renal impairment.' Effective hypertension management aims to prevent complications such as renal impairment. Checking for signs of kidney issues, like abnormal renal function tests, is crucial in monitoring the client's condition. Choices A, B, and D are not specific indicators of effective hypertension management. Pedal edema, sexual dysfunction, and a single blood pressure reading are important but do not solely determine the effectiveness of managing hypertension.