Nokea
A client with a history of alcoholism is admitted with confusion, ataxia, and nystagmus. Which nursing intervention is a priority for this client?
- A. Monitor for signs of alcohol withdrawal.
- B. Administer thiamine as prescribed.
- C. Provide a quiet environment to reduce confusion.
- D. Initiate fall precautions.
Correct Answer: B
Rationale: The correct answer is B: Administer thiamine as prescribed. Administering thiamine is crucial in clients with a history of alcoholism to prevent Wernicke's encephalopathy, which is characterized by confusion, ataxia, and nystagmus. Monitoring for signs of alcohol withdrawal (choice A) is important but not the priority. Providing a quiet environment (choice C) and initiating fall precautions (choice D) are important interventions, but administering thiamine takes precedence due to the risk of Wernicke's encephalopathy.
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A client with hypertension receives a prescription for enalapril, an angiotensin-converting enzyme inhibitor (ACEI). Which instruction should the nurse include in the medication teaching plan?
- A. Increase intake of potassium-rich foods
- B. Report increased bruising or bleeding
- C. Stop medication if a cough develops
- D. Limit intake of leafy green vegetables
Correct Answer: B
Rationale: The correct instruction for the nurse to include in the medication teaching plan for a client receiving enalapril, an ACE inhibitor, is to 'Report increased bruising or bleeding.' ACE inhibitors can cause thrombocytopenia, which can lead to an increased risk of bruising and bleeding. Monitoring and reporting these symptoms promptly are essential to prevent complications. Choices A, C, and D are incorrect because increasing potassium-rich foods, stopping medication if a cough develops, and limiting intake of leafy green vegetables are not directly related to the common side effects or actions of ACE inhibitors.
A client with chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Which assessment finding requires immediate intervention?
- A. Oxygen saturation of 90%
- B. Respiratory rate of 24 breaths per minute
- C. Use of accessory muscles
- D. Inspiratory crackles
Correct Answer: C
Rationale: The correct answer is C. The use of accessory muscles indicates increased work of breathing and can signal respiratory failure in a client with COPD. This finding requires immediate intervention to prevent further respiratory compromise. Oxygen saturation of 90% indicates some oxygenation impairment but may not necessitate immediate intervention. A respiratory rate of 24 breaths per minute is slightly elevated but does not indicate immediate respiratory distress. Inspiratory crackles may be present in pneumonia but do not require immediate intervention compared to the increased work of breathing indicated by the use of accessory muscles.
Which assessment is most important for the nurse to include in the daily plan of care for a client with a burned extremity?
- A. Distal pulse intensity
- B. Skin integrity
- C. Pain levels
- D. Range of motion
Correct Answer: A
Rationale: The correct answer is A: Distal pulse intensity. Monitoring distal pulses is crucial to ensure that circulation to the extremity is not compromised. This assessment helps in detecting any signs of decreased circulation, which is vital in managing a burned extremity. While skin integrity (choice B), pain levels (choice C), and range of motion (choice D) are also important assessments, monitoring distal pulse intensity takes precedence as it directly reflects the perfusion status of the affected extremity in a burned client.
A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear results are negative. What information should the nurse include in the client's teaching plan?
- A. Further evaluation involving surgery may be needed
- B. A pelvic exam is also needed before cancer is ruled out
- C. Pap smear evaluation should be continued every six months
- D. One additional negative Pap smear in six months is needed
Correct Answer: A
Rationale: In a 60-year-old female client with a family history of ovarian cancer and an abdominal mass, further evaluation involving surgery may be needed to rule out ovarian cancer. The presence of an abdominal mass raises suspicion for a possible malignancy, and a negative Pap smear result does not rule out ovarian cancer. A pelvic exam alone may not provide sufficient information to confirm or rule out ovarian cancer. Continuing Pap smear evaluations every six months or waiting for one additional negative Pap smear in six months is not appropriate in this scenario, as the abdominal mass requires immediate attention and further evaluation.
A client is admitted for type 2 diabetes mellitus (DM) and chronic kidney disease (CKD). Which breakfast selection by the client indicates effective learning?
- A. Scrambled eggs, bacon, one slice of whole wheat toast with butter and jam.
- B. Oatmeal with butter, artificial sweetener, and strawberries, and 6 ounces of coffee.
- C. Banana pancake with maple syrup, sausage links, half grapefruit, and low-fat milk.
- D. Orange juice, yogurt with berries, cold cereal with milk, bran muffin with margarine.
Correct Answer: B
Rationale: The correct answer is B. Oatmeal with butter, artificial sweetener, and strawberries is a suitable choice for a client with type 2 diabetes mellitus and chronic kidney disease as it provides a balanced meal that helps manage blood sugar levels and kidney function. Choice A contains high saturated fats and added sugars from bacon, butter, and jam, which are not ideal for this client. Choice C includes high sugar content from maple syrup and pancake, which can negatively impact blood sugar levels. Choice D contains high sugar content from orange juice and cold cereal, which can lead to blood sugar spikes, not suitable for a client with diabetes and CKD.