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A client receiving codeine for pain every 4 to 6 hours over 4 days. Which assessment should the nurse perform before administering the next dose?
- A. Auscultate the bowel sounds.
- B. Palpate the ankles for edema.
- C. Observe the skin for bruising.
- D. Measure the body temperature.
Correct Answer: A
Rationale: The correct answer is A: Auscultate the bowel sounds. Codeine is known to cause constipation, so it is essential to assess bowel sounds before administering another dose to monitor for potential constipation or bowel motility issues. Palpating the ankles for edema (Choice B) is not directly related to codeine use or its side effects. Observing the skin for bruising (Choice C) is important but not specifically associated with codeine administration. Measuring body temperature (Choice D) is not a priority assessment related to codeine use; monitoring for constipation is more critical in this case.
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An 11-year-old client admitted to the mental health unit after threatening self-harm. What is the best activity to establish rapport and promote coping?
- A. Bring the client to the team meeting to discuss the treatment plan.
- B. Play a board game with the client and start discussing stressors.
- C. Explain the purpose of each medication the client is taking.
- D. Ask the client to write feelings in a journal and review together.
Correct Answer: B
Rationale: Playing a board game with the client is an effective way to establish rapport in a relaxed setting, allowing the client to open up about stressors. This activity promotes coping by creating a safe and engaging environment for the client to express their feelings. Choices A, C, and D may not be suitable initially as they involve more formal or intrusive approaches that may not be suitable for building rapport with a client experiencing emotional distress.
A client receiving total parenteral nutrition (TPN) is experiencing nausea and vomiting. What is the nurse's first action?
- A. Check the client's blood glucose level.
- B. Decrease the rate of TPN infusion.
- C. Administer an antiemetic as prescribed.
- D. Check the client's TPN bag for solution accuracy.
Correct Answer: D
Rationale: The correct first action for the nurse to take when a client receiving TPN is experiencing nausea and vomiting is to check the client's TPN bag for solution accuracy. This is crucial to ensure that the correct solution is being administered and to address any potential errors. Checking the blood glucose level or administering an antiemetic may be necessary interventions but addressing the TPN bag's accuracy should be the priority to prevent any complications related to incorrect TPN solution.
A client with peripheral artery disease reports pain while walking. What intervention should the nurse recommend?
- A. Encourage the client to increase physical activity.
- B. Instruct the client to take rest breaks during walking.
- C. Apply warm compresses to the legs to improve circulation.
- D. Massage the affected leg to relieve the pain.
Correct Answer: B
Rationale: Clients with peripheral artery disease often experience claudication (leg pain during walking) due to decreased blood flow. Encouraging rest breaks during walking helps to manage pain and improve circulation. Rest breaks allow the muscles to recover from ischemia caused by inadequate blood supply. Increasing physical activity without breaks may worsen the symptoms. Applying warm compresses can potentially lead to burns or skin damage in individuals with compromised circulation. Massaging the affected leg is contraindicated in peripheral artery disease as it can further compromise blood flow.
A client with chronic kidney disease is admitted with complaints of fatigue and swelling in the lower extremities. What laboratory finding is most important for the nurse to report?
- A. Serum creatinine level of 2.0 mg/dL.
- B. Hemoglobin level of 8 g/dL.
- C. Potassium level of 5.6 mEq/L.
- D. Blood urea nitrogen (BUN) level of 25 mg/dL.
Correct Answer: B
Rationale: The correct answer is B. A hemoglobin level of 8 g/dL suggests anemia, which commonly occurs in clients with chronic kidney disease and requires prompt intervention. Reporting this finding is crucial to address the anemic condition. Choices A, C, and D are important in the context of chronic kidney disease but do not directly relate to the symptoms of fatigue and swelling in the lower extremities described in the scenario.
The healthcare provider prescribes a sepsis protocol for a client with multi-organ failure caused by a ruptured appendix. Which intervention is most important for the nurse to include in the care plan?
- A. Ensure early ambulation
- B. Administer antibiotics as prescribed
- C. Maintain strict intake and output
- D. Monitor blood glucose levels
Correct Answer: C
Rationale: In sepsis with multi-organ failure, monitoring intake and output is critical to assess renal function and fluid balance, as organ failure can cause fluid shifts and decreased kidney function. Antibiotics are essential to treat the infection, but monitoring intake and output provides real-time insight into the client's status, helping to detect early signs of worsening organ function. Early ambulation and blood glucose monitoring are important aspects of care but are not as crucial as maintaining strict intake and output in this situation.