Nokea
A client with a fractured femur has a BP of 140/94 mmHg and denies any history of HTN. Which of the following actions should the nurse take first?
- A. Request a prescription for an antihypertensive medication.
- B. Ask the client if they are having pain.
- C. Request a prescription for an antianxiety medication.
- D. Return in 30 minutes to recheck the client's BP.
Correct Answer: B
Rationale: The correct action is to ask the client if they are having pain. Pain can lead to temporary increases in blood pressure. Addressing pain as a potential cause is the initial step before considering medication adjustments. Requesting an antihypertensive medication or an antianxiety medication without assessing pain first would not address the immediate concern. Returning to recheck the BP can be done after addressing the potential pain issue.
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The client is being discharged and has been prescribed furosemide (Lasix). Which statement by the client indicates an understanding of the medication?
- A. I will take this medication on an empty stomach for optimal absorption.
- B. I will weigh myself daily and report any significant weight loss.
- C. I will include potassium-rich foods in my diet while taking this medication.
- D. I will take this medication in the morning to prevent nocturia.
Correct Answer: B
Rationale: The correct answer is B. Weighing daily and reporting significant weight loss is crucial when taking furosemide to monitor for potential fluid and electrolyte imbalances. Choice A is incorrect because furosemide is typically taken on an empty stomach for optimal absorption. Choice C is incorrect as furosemide can lead to potassium loss, so potassium-rich foods should be consumed. Choice D is incorrect because furosemide is usually taken earlier in the day to prevent nocturia, not at bedtime.
A client with chronic back pain asks a nurse about receiving acupuncture for relief. Which of the following findings should the nurse identify as a contraindication to receiving this treatment?
- A. Obesity
- B. Hypertension
- C. Migraines
- D. Cellulitis
Correct Answer: D
Rationale: The correct answer is D, Cellulitis. Cellulitis is a contraindication for acupuncture due to the risk of infection. Acupuncture involves inserting needles into the skin, and if a person has cellulitis, which is a bacterial skin infection, there is a higher risk of introducing the infection deeper into the body. Obesity (choice A), hypertension (choice B), and migraines (choice C) are not contraindications for receiving acupuncture. These conditions do not pose a direct risk of complications related to acupuncture treatment.
While ambulating an unsteady client who begins to fall, which of the following actions should the nurse take?
- A. Allow the client to slide down their outstretched leg.
- B. Place their arms around the client to prevent the fall.
- C. Remain upright as the client falls toward them.
- D. Move quickly to a position in front of the client.
Correct Answer: A
Rationale: When a client is falling, allowing them to slide down your leg can help control the descent and prevent injury. This technique ensures a more controlled fall compared to attempting to catch or stop the client abruptly, which could lead to both the client and the nurse getting injured. Placing arms around the client may not provide enough support or control during the fall. Remaining upright or moving quickly in front of the client might not be practical or safe in this scenario.
When using an open irrigation technique for a client's catheter, what action should the nurse take?
- A. Subtract the amount of irrigant used from the client's urine output.
- B. Add the amount of irrigant used to the urine output measurement.
- C. Measure the amount of irrigant used separately from the urine output.
- D. Document the total amount of fluid used for irrigation only.
Correct Answer: A
Rationale: The correct action for the nurse to take when using an open irrigation technique for a client's catheter is to subtract the amount of irrigant used from the client's urine output. This subtraction helps accurately assess the client's output by accounting for the volume of irrigant introduced. Choice B is incorrect because adding the irrigant to the urine output measurement would falsely inflate the total output, leading to inaccurate assessment. Choice C is incorrect as measuring the amount of irrigant separately does not provide an accurate assessment of the client's total output as it disregards the irrigant's contribution. Choice D is incorrect as documenting the total fluid used for irrigation only does not differentiate between the irrigant and the client's actual urine output, which is crucial for accurate monitoring and assessment.
The client is being taught about the use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?
- A. Remove the needle after discarding used syringes
- B. Wear gloves while disposing of the needle and syringe
- C. Wear a face mask during medication administration
- D. Wash hands before handling the needle and syringe
Correct Answer: D
Rationale: The correct answer is D. Washing hands before handling the needle and syringe is a critical step in infection control and adherence to standard precautions. Clean hands help prevent the transfer of microorganisms and reduce the risk of infection. Choices A, B, and C do not directly relate to standard precautions. Removing the needle after discarding used syringes (Choice A) can increase the risk of needlestick injuries. Wearing gloves while disposing of the needle and syringe (Choice B) is important for personal protection but does not specifically address standard precautions. Wearing a face mask during medication administration (Choice C) is not directly related to handling syringes and needles, which are more pertinent to standard precautions.