Nokea
A client presents to the labor and delivery unit, screaming 'THE BABY IS COMING.' Which action should the nurse implement first?
- A. Observe the perineum
- B. Prepare the delivery room
- C. Call the obstetrician
- D. Administer pain relief
Correct Answer: A
Rationale: Observing the perineum is the priority action for the nurse in this situation. It allows the nurse to assess the stage of labor, determine the urgency of the situation, and provide immediate assistance if the baby is indeed about to be delivered. Preparing the delivery room and calling the obstetrician can follow once the nurse has assessed the situation. Administering pain relief may not be the immediate priority when the baby is coming.
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The nurse is caring for a client with a chest tube in place following a pneumothorax. Which finding requires immediate intervention?
- A. Oxygen saturation of 95%
- B. Crepitus around the insertion site
- C. Subcutaneous emphysema
- D. Drainage of 50 ml per hour
Correct Answer: C
Rationale: Subcutaneous emphysema requires immediate intervention in a client with a chest tube following a pneumothorax as it can indicate a pneumothorax recurrence or air leak. Oxygen saturation of 95% is within the normal range and does not require immediate intervention. Crepitus around the insertion site can be expected post-procedure and may not necessitate immediate action. Drainage of 50 ml per hour is a normal finding and does not raise immediate concerns.
A client with type 2 diabetes is admitted with hyperglycemic hyperosmolar syndrome (HHS). Which intervention should the nurse implement first?
- A. Administer intravenous fluids.
- B. Monitor the client's urine output.
- C. Obtain a blood glucose level.
- D. Administer 50% dextrose IV push.
Correct Answer: D
Rationale: The correct answer is to administer 50% dextrose IV push first. In hyperglycemic hyperosmolar syndrome, the main goal is to rapidly reduce blood glucose levels to prevent further complications. Administering dextrose intravenously can help reverse the effects of high blood glucose levels quickly. Administering intravenous fluids, monitoring urine output, and obtaining a blood glucose level are important interventions but are not the first priority in treating HHS. Administering 50% dextrose IV push takes precedence as it directly addresses the elevated blood glucose levels.
A client with end-stage renal disease (ESRD) is receiving hemodialysis. Which laboratory value should the nurse monitor closely?
- A. Serum calcium level of 9 mg/dl
- B. Serum potassium level of 4.5 mEq/L
- C. Serum creatinine level of 2.0 mg/dl
- D. Serum sodium level of 138 mEq/L
Correct Answer: C
Rationale: The correct answer is C: Serum creatinine level of 2.0 mg/dl. In a client with ESRD receiving hemodialysis, serum creatinine should be closely monitored. Elevated creatinine levels indicate impaired kidney function. Monitoring serum calcium levels (Choice A), serum potassium levels (Choice B), and serum sodium levels (Choice D) is also important in clients with ESRD, but the most crucial indicator of kidney function in this case is serum creatinine.
An adult female client with chronic kidney disease (CKD) asks the nurse if she can continue taking over-the-counter medications. Which medication provides the greatest threat to this client?
- A. Magnesium hydroxide (Maalox).
- B. Birth control pills.
- C. Cough syrup containing codeine.
- D. Cold medication containing alcohol.
Correct Answer: A
Rationale: The correct answer is A: Magnesium hydroxide (Maalox). In clients with CKD, magnesium can accumulate to toxic levels due to decreased excretion by the kidneys. Therefore, it poses the greatest threat to this client population. Choice B, birth control pills, is not typically contraindicated in CKD. Choice C, cough syrup containing codeine, may require dose adjustments but is not the greatest threat. Choice D, cold medication containing alcohol, is a concern mainly in liver disease, not CKD.
A client with a history of chronic heart failure is admitted with shortness of breath and crackles in the lungs. Which laboratory value should be closely monitored?
- A. Serum creatinine of 2.0 mg/dL
- B. Serum sodium of 135 mEq/L
- C. Serum potassium of 5.5 mEq/L
- D. Blood glucose of 150 mg/dL
Correct Answer: C
Rationale: A serum potassium level of 5.5 mEq/L should be closely monitored in a client with chronic heart failure as it may indicate hyperkalemia, requiring intervention. Hyperkalemia can lead to life-threatening cardiac arrhythmias in patients with heart failure. Serum creatinine (Choice A) is important to monitor for kidney function but is not the priority in this case. Serum sodium (Choice B) and blood glucose (Choice D) levels are not typically the primary focus when assessing a client with heart failure presenting with respiratory symptoms and crackles in the lungs.