Nokea
Select the 5 actions the nurse should take.
- A. Provide frequent rest periods for the client.
- B. Restrict the client's sodium intake
- C. Advise the client to avoid the use of soap and alcohol-based lotions
- D. Place the client on a low-carbohydrate diet
- E. Place the client under contact isolation.
- F. Instruct the client to avoid blowing their nose forcefully
- G. Assess the client's level of orientation
Correct Answer: A,B,C,E,F,G
Rationale: The correct actions the nurse should take are A, B, C, E, F, and G. A: Providing rest periods promotes healing. B: Restricting sodium intake is crucial for certain health conditions. C: Avoiding soap and alcohol-based lotions can prevent skin irritation. E: Placing the client under contact isolation is necessary to prevent the spread of infection. F: Instructing the client to avoid blowing their nose forcefully prevents injury. G: Assessing the client's level of orientation is essential for monitoring their mental status. Other choices are incorrect because a low-carbohydrate diet (D) is not mentioned, and it is not a priority action in this scenario.
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Which of the following actions should the nurse take first?
- A. Determine the client's Glasgow Coma Scale score
- B. Insert an indwelling urinary catheter for the client.
- C. Administer mannitol IV bolus to the client
- D. Prepare the client for an MRI of the brain.
Correct Answer: A
Rationale: The correct answer is A: Determine the client's Glasgow Coma Scale (GCS) score. This is the priority action as it helps assess the client's level of consciousness and neurological status quickly. It guides further interventions and treatment decisions. Inserting an indwelling urinary catheter (B) or administering mannitol IV bolus (C) may be needed but assessing neurological status comes first. Preparing for an MRI (D) is important but not the initial step.
For each potential provider prescription click to specify if the prescription is anticipated or contraindicated for the client.
- A. Administer famotidine 20 mg via intermittent IV infusion twice daily.
- B. insert an indwelling urinary catheter.
- C. Administer lactated Ringer's 1L via IV bolus.
- D. Insert a nasogastric tube and maintain low intermittent suction.
Correct Answer: A,C,D
Rationale: [Explanation: The correct answer is - A,C,D. Administering famotidine helps reduce stomach acid, beneficial for clients with gastric issues. Lactated Ringer's IV bolus helps with fluid resuscitation. Inserting a nasogastric tube can help with decompression or feeding. Inserting an indwelling urinary catheter is not typically provider-initiated unless medically necessary. Therefore, A, C, and D are anticipated for client care, while B is contraindicated unless specifically indicated.]
Which of the following is an appropriate action by the nurse?
- A. Suggest rinsing his mouth with an alcohol-based mouth wash
- B. Provide humidification of the room air.
- C. Offer the client saltine crackers between meals
- D. Instruct the client on the use of esophageal speech
Correct Answer: B
Rationale: The correct answer is B: Provide humidification of the room air. Humidification helps to moisturize the air, making it easier for the client to breathe, especially if they have dry mouth or throat. This can improve comfort and prevent irritation. Choice A is incorrect because alcohol-based mouthwash can further dry out the mouth. Choice C is incorrect as saltine crackers can exacerbate dry mouth. Choice D is incorrect as esophageal speech is not related to addressing dry mouth.
Which of the following manifestations should the nurse expect?
- A. Drooling
- B. Malaise
- C. Tinnitus
- D. Rhinorrhea
Correct Answer: B
Rationale: The correct answer is B: Malaise. Malaise is a general feeling of discomfort or unease, commonly seen in various health conditions. In this scenario, malaise can be an expected manifestation due to its non-specific nature and association with underlying illnesses. Drooling (A), tinnitus (C), and rhinorrhea (D) are not typically associated with the given context and are less likely to be expected manifestations.
For each potential nursing action, click to specify if the action is indicated or not indicated for the client.
- A. Document the blood product transfusion in the client's medical record.
- B. Stay with the client for the first 15 min of the transfusion
- C. Titrate the rate of infusion to maintain the client's blood pressure at least 91/60 mm. Hg
- D. Obtain the first unit of packed RBCS from the blood bank.
- E. Start an IV bolus of lactated Ringers solution.
Correct Answer: A,B,D
Rationale: [A: 1, B: 1, C: 0, D: 1, E: 0, F: , G: ]
- A: Documenting blood product transfusion is crucial for legal and tracking purposes.
- B: Staying with the client ensures immediate response to any adverse reactions.
- C: Titration of infusion rate for BP is not within nursing scope without physician order.
- D: Obtaining packed RBCs precedes transfusion to verify compatibility.
- E: Starting IV bolus of LR is not indicated as it is unrelated to the transfusion process.