Nokea
A client receiving morphine via patient-controlled analgesia (PCA) should have naloxone administered if their respiratory rate is below 10/min. What action should the nurse take?
- A. Monitor the client's blood pressure every 4 hours.
- B. Ask the client to rate their pain every 2 hours.
- C. Administer naloxone if the client's respiratory rate is below 10/min.
- D. Evaluate the client's use of the PCA every 4 hours.
Correct Answer: C
Rationale: The correct action for the nurse to take is to administer naloxone if the client's respiratory rate falls below 10/min. Naloxone is used to reverse opioid-induced respiratory depression, which is a life-threatening situation. Monitoring the client's blood pressure every 4 hours (Choice A) is not the priority in this scenario as respiratory depression requires immediate attention. Asking the client to rate their pain every 2 hours (Choice B) is important for pain management but addressing respiratory depression takes precedence. Evaluating the client's use of the PCA every 4 hours (Choice D) is a routine nursing intervention but does not directly address the urgent need to reverse respiratory depression in this case.
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A client with chronic kidney disease is receiving dietary teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?
- A. I will increase my intake of bananas.
- B. I will limit my intake of foods high in potassium.
- C. I will increase my intake of protein-rich foods.
- D. I will increase my intake of dairy products.
Correct Answer: B
Rationale: The correct answer is B. Limiting potassium-rich foods is crucial for clients with chronic kidney disease to prevent hyperkalemia, a common complication. Increasing intake of potassium-rich foods like bananas (choice A), protein-rich foods (choice C), or dairy products (choice D) can exacerbate hyperkalemia in these clients. Bananas, protein-rich foods, and dairy products are all high in potassium, which is detrimental for individuals with chronic kidney disease. Therefore, choices A, C, and D are incorrect.
A nurse is providing discharge teaching to a client who has a new prescription for albuterol. Which of the following instructions should the nurse include?
- A. You should take this medication at bedtime.
- B. You might experience palpitations while taking this medication.
- C. You should rinse your mouth after using this medication.
- D. You should avoid eating before taking this medication.
Correct Answer: C
Rationale: The correct answer is C: 'You should rinse your mouth after using this medication.' When providing discharge teaching for a client prescribed albuterol, the nurse should include the instruction to rinse the mouth after each use. This is important to prevent dry mouth and oral infections. Choice A is incorrect as albuterol is usually taken during the day to manage symptoms, not at bedtime. Choice B is incorrect as palpitations are not a common side effect of albuterol. Choice D is incorrect as there is no specific requirement to avoid eating before taking albuterol.
A nurse is providing dietary teaching to a client who is at 8 weeks of gestation and has a body mass index (BMI) of 24. Which of the following instructions should the nurse include?
- A. You should increase your caloric intake by 600 calories per day.
- B. You should increase your caloric intake by 300 calories per day.
- C. You should maintain your prepregnancy caloric intake during the first trimester.
- D. You should increase your caloric intake by 150 calories per day.
Correct Answer: B
Rationale: During the first trimester, it is recommended to increase caloric intake by 300 calories per day to support fetal growth and development. Choice A suggesting an increase of 600 calories is excessive and unnecessary. Choice C advising to maintain prepregnancy caloric intake could lead to inadequate nutrition for the developing fetus. Choice D recommending an increase of 150 calories is insufficient to meet the increased energy demands of pregnancy.
A client has thrombocytopenia. What action should the nurse include?
- A. Encourage the client to floss daily.
- B. Remove fresh flowers from the client's room.
- C. Provide the client with a stool softener.
- D. Avoid serving raw vegetables.
Correct Answer: C
Rationale: The correct action for the nurse when caring for a client with thrombocytopenia is to provide the client with a stool softener. Thrombocytopenia is characterized by a low platelet count, leading to increased bleeding tendencies. Providing a stool softener helps prevent constipation, reducing the likelihood of straining during bowel movements and subsequent bleeding. Encouraging the client to floss daily (choice A) is unrelated to managing thrombocytopenia. Removing fresh flowers from the client's room (choice B) pertains more to infection control than addressing thrombocytopenia. Avoiding serving raw vegetables (choice D) is not directly associated with managing thrombocytopenia symptoms.
When using an IV pump for a newly admitted client, what action should the nurse take?
- A. Grasp the IV pump cord when unplugging it from the electrical outlet.
- B. Ensure the pump is plugged into an outlet with two prongs.
- C. Hold the IV pump cord while walking the client.
- D. Check for malfunctioning pump alerts.
Correct Answer: C
Rationale: The correct action for the nurse to take when using an IV pump for a newly admitted client is to hold the IV pump cord while walking the client. This is important for ensuring the safe and secure management of the IV pump during client mobility. Option A is incorrect as grasping the IV pump cord when unplugging it can lead to electrical hazards. Option B is incorrect as ensuring the pump is plugged into an outlet with two prongs is important for electrical safety but not directly related to the nurse's action. Option D is also important but does not directly address the nurse's immediate action while using the IV pump with the client.