Nokea
A client reports feeling dizzy and light-headed when standing up. What is the nurse's best initial action?
- A. Instruct the client to sit or lie down
- B. Monitor blood pressure and pulse
- C. Administer an anti-dizziness medication
- D. Increase fluid intake
Correct Answer: B
Rationale: The correct answer is B: Monitor blood pressure and pulse. When a client reports feeling dizzy and light-headed when standing up, the nurse's best initial action should be to monitor the client's blood pressure and pulse. These symptoms are indicative of orthostatic hypotension, which can be confirmed by changes in blood pressure and pulse when moving from lying to standing positions. Instructing the client to sit or lie down may provide temporary relief but does not address the underlying cause. Administering an anti-dizziness medication should not be the initial action without assessing vital signs first. Increasing fluid intake is important for overall health but is not the priority in this situation where vital sign monitoring is needed to assess for orthostatic hypotension.
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Which client assessment falls within the scope of practice for the practical nurse?
- A. An agitated client with bilateral wrist restraints
- B. New admission of a client with deep vein thrombosis
- C. Return of a post-anesthesia client following a colon resection
- D. Transfer of a client with sepsis from a long-term care facility
Correct Answer: B
Rationale: The correct answer is B because assessing a new deep vein thrombosis (DVT) patient is within the scope of practical nursing. It involves monitoring and supporting the circulatory system health, which is a common responsibility for practical nurses. Choices A, C, and D involve scenarios that are typically beyond the initial assessment and care provided by practical nurses. An agitated client with bilateral wrist restraints may require immediate intervention by higher-level healthcare providers due to safety concerns and potential underlying issues. The return of a post-anesthesia client following a colon resection and the transfer of a client with sepsis involve more specialized care that goes beyond the typical responsibilities of a practical nurse, often requiring interventions from registered nurses or physicians.
A client is admitted with Atrial Fibrillation and is administered amiodarone (Cordarone). What therapeutic response should the nurse anticipate?
- A. Conversion of irregular heart rate to regular heart rhythm
- B. Pulse oximetry readings within normal range during activity
- C. Peripheral pulse points with adequate capillary refill
- D. Increase in exercise tolerance without shortness of breath
Correct Answer: A
Rationale: The correct answer is A: Conversion of irregular heart rate to regular heart rhythm. Amiodarone is a medication commonly used to restore and maintain normal heart rhythm in clients with atrial fibrillation. It works by slowing down the electrical signals in the heart, helping to regulate the heartbeat. Choices B, C, and D are incorrect because they do not directly relate to the therapeutic response expected from administering amiodarone in a client with atrial fibrillation. Pulse oximetry readings, peripheral pulses, capillary refill, and exercise tolerance are important assessments but are not the primary therapeutic goal of using amiodarone in this situation.
Which nonfood item is the most common cause of respiratory arrest in young children?
- A. Broken rattles
- B. Buttons
- C. Pacifiers
- D. Latex balloons
Correct Answer: D
Rationale: The correct answer is D, Latex balloons. Latex balloons can pose a significant choking hazard to young children if inhaled, potentially leading to respiratory arrest. Broken rattles, buttons, and pacifiers are not typically known to cause respiratory arrest in young children. While these items can present choking hazards as well, the most common cause of respiratory arrest among young children is due to inhaling latex balloons.
A client with diabetes mellitus is admitted with hyperglycemia. What is the priority nursing action?
- A. Administer insulin as prescribed
- B. Encourage fluid intake
- C. Monitor blood glucose levels frequently
- D. Assess for signs of hypoglycemia
Correct Answer: A
Rationale: Administering insulin is the priority nursing action for a client admitted with hyperglycemia due to diabetes mellitus. Insulin helps lower blood glucose levels and prevent further complications associated with hyperglycemia. Encouraging fluid intake is important but not the priority as insulin administration takes precedence to address the immediate hyperglycemic state. Monitoring blood glucose levels frequently is essential but comes after administering insulin to ensure the treatment's effectiveness. Assessing for signs of hypoglycemia is incorrect as the client is admitted with hyperglycemia, which requires raising blood glucose levels, not lowering them further.
An adult female client is admitted to the psychiatric unit with a diagnosis of major depression. After 2 weeks of antidepressant medication therapy, the nurse notices the client has more energy, is giving her belongings away to her visitors, and is in an overall better mood. Which intervention is best for the nurse to implement?
- A. Tell the client to keep her belongings because she will need them at discharge
- B. Ask the client if she has had any recent thoughts of harming herself
- C. Reassure the client that the antidepressant drugs are apparently effective
- D. Support the client by telling her what wonderful progress she is making
Correct Answer: B
Rationale: In this scenario, the nurse should ask the client if she has had any recent thoughts of harming herself. Sudden mood improvements and behavioral changes, like giving away belongings, can be concerning signs of possible suicidal ideation. Assessing for suicidal thoughts is crucial to ensure the client's safety. Choice A is incorrect as it does not address the potential risk of harm or assess for suicidal ideation. Choice C is incorrect because simply reassuring the client about the effectiveness of antidepressants does not address the immediate concern of suicidal ideation. Choice D is incorrect as it focuses on praising progress without addressing the potential risk of harm the client may pose to herself.