Nokea
A client with a history of chronic alcoholism is admitted with confusion, ataxia, and diplopia. 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 to administer thiamine as prescribed. This intervention is a priority for clients with chronic alcoholism to prevent Wernicke's encephalopathy, a serious complication of thiamine deficiency. Monitoring for signs of alcohol withdrawal (choice A) is important but not the priority in this scenario. Providing a quiet environment (choice C) may be beneficial but does not address the immediate need to prevent Wernicke's encephalopathy. Initiating fall precautions (choice D) is also important but not the priority compared to administering thiamine to prevent a life-threatening condition.
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The nurse is assessing a female client's blood pressure because she reported feeling dizzy. The blood pressure cuff is inflated to 140 mm Hg and as soon as the cuff is deflated a Korotkoff sound is heard. Which intervention should the nurse implement next?
- A. Wait 1 minute and palpate the systolic pressure before auscultating again.
- B. Increase the inflation pressure by 20 mm Hg and measure again.
- C. Switch to a larger cuff and repeat the measurement.
- D. Document the finding as normal.
Correct Answer: A
Rationale: If a Korotkoff sound is heard immediately upon deflation, it may indicate an inaccurate reading. Waiting and palpating the systolic pressure can help confirm the accuracy of the measurement. Choice A is the correct intervention because it allows the nurse to ensure the accuracy of the blood pressure reading. Choice B is incorrect as increasing the inflation pressure is not necessary in this situation. Choice C is also incorrect as switching to a larger cuff is not warranted based on the information provided. Choice D is incorrect because documenting the finding as normal without further verification could lead to inaccurate information.
A nurse is teaching a client with type 2 diabetes about the importance of foot care. Which statement by the client indicates a need for further teaching?
- A. I should check my feet every day for cuts or blisters.
- B. I need to moisturize my feet daily, especially between my toes.
- C. I should wear comfortable shoes that fit well.
- D. I should avoid walking barefoot, even indoors.
Correct Answer: B
Rationale: The correct answer is B. Moisturizing between the toes can create a moist environment that fosters fungal infections. Checking the feet daily for cuts or blisters (choice A) is correct in diabetes management to prevent complications. Wearing comfortable shoes that fit well (choice C) and avoiding walking barefoot (choice D) are also essential in preventing foot ulcers and injuries in diabetic patients.
In preparing assignments for the shift, which client is best for the charge nurse to assign to a practical nurse (PN)?
- A. An older client who fell yesterday and is now complaining of diplopia.
- B. An adult newly diagnosed with type 1 diabetes and high cholesterol.
- C. A client with pancreatic cancer who is experiencing intractable pain.
- D. An older client post-stroke who is aphasic with right-sided hemiplegia.
Correct Answer: D
Rationale: The best client for the charge nurse to assign to a practical nurse (PN) is an older client post-stroke who is aphasic with right-sided hemiplegia. This client is stable and suitable for care by a PN under supervision. Choices A, B, and C present clients with more complex and acute conditions that would require a higher level of nursing expertise and intervention.
A client is receiving continuous bladder irrigation via a triple-lumen suprapubic catheter that was placed during a prostatectomy. Which report by the unlicensed assistive personnel (UAP) requires intervention by the nurse?
- A. Leakage around the catheter insertion site.
- B. Pink-tinged urine in the drainage bag.
- C. Client reports discomfort at the catheter site.
- D. Decreased urine output in the last hour.
Correct Answer: A
Rationale: The correct answer is A. Leakage around the catheter insertion site may indicate a problem with the catheter placement or function, requiring immediate intervention. Pink-tinged urine in the drainage bag is expected due to the continuous bladder irrigation. Discomfort at the catheter site is common after the procedure. Decreased urine output in the last hour may be due to the continuous bladder irrigation and doesn't require immediate intervention.
A client with a history of atrial fibrillation is admitted with a new onset of confusion. Which laboratory value should the nurse monitor closely?
- A. International Normalized Ratio (INR)
- B. Serum glucose level
- C. White blood cell count
- D. Prothrombin time (PT)
Correct Answer: A
Rationale: The correct answer is A: International Normalized Ratio (INR). The INR should be closely monitored in a client with atrial fibrillation to assess the effectiveness and safety of anticoagulation therapy with warfarin. Monitoring the INR helps to ensure that the client is within the therapeutic range to prevent complications such as thrombosis or bleeding. Choices B, C, and D are less relevant in this scenario. While serum glucose levels are important in assessing metabolic status, and white blood cell count and prothrombin time are important indicators for other conditions, they are not the primary focus when a client with atrial fibrillation presents with confusion.