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A client with a history of closed head injury has a radial artery catheter in place and complains of numbness and pain distal to the insertion site. What action should the nurse take?
- A. Monitor the site for further complications.
- B. Promptly remove the catheter from the radial artery.
- C. Elevate the client's arm above the heart.
- D. Notify the healthcare provider and prepare for surgery.
Correct Answer: B
Rationale: A weak pulse and numbness distal to a radial artery catheter may indicate occlusion or damage to the artery, and immediate removal of the catheter is necessary to prevent complications. Therefore, promptly removing the catheter from the radial artery (Choice B) is the correct action. Monitoring the site (Choice A) would delay necessary intervention, elevating the client's arm (Choice C) may not address the underlying issue, and notifying the healthcare provider for surgery (Choice D) without removing the catheter promptly could lead to further complications.
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A client is diagnosed with Meniere's disease. Which problem should the nurse identify as most important in the plan of care?
- A. Social isolation related to hearing loss
- B. Risk for injury related to vertigo
- C. Impaired verbal communication
- D. Impaired hearing related to ear disease
Correct Answer: B
Rationale: Vertigo is the primary symptom of Meniere's disease and can lead to falls and other injuries. Ensuring safety and addressing the risk of injury is the nurse's top priority. While social isolation and impaired hearing are significant concerns associated with Meniere's disease, the immediate danger of falls due to vertigo takes precedence in the plan of care. Impaired verbal communication, although important, is not as urgent as preventing injuries caused by vertigo.
A client with acute kidney injury (AKI) is experiencing hyperkalemia. What intervention should the nurse prioritize?
- A. Administer IV calcium gluconate.
- B. Administer sodium polystyrene sulfonate (Kayexalate).
- C. Administer insulin with dextrose.
- D. Restrict potassium intake in the client's diet.
Correct Answer: A
Rationale: The correct intervention for a client with acute kidney injury (AKI) experiencing hyperkalemia is to administer IV calcium gluconate. Calcium gluconate helps stabilize the myocardium and prevent life-threatening arrhythmias in hyperkalemia by antagonizing the cardiac effects of high potassium levels. Choice B, administering sodium polystyrene sulfonate (Kayexalate), is used to lower potassium levels in the gastrointestinal tract but is not the priority in acute severe hyperkalemia. Choice C, administering insulin with dextrose, helps drive potassium into cells but is not the priority in a client at risk for arrhythmias due to hyperkalemia. Choice D, restricting potassium intake in the client's diet, is a long-term strategy but is not the immediate priority in managing acute hyperkalemia.
When assessing a recently delivered multigravida client, the nurse finds that her vaginal bleeding is more than expected. Which factor in this client's history is related to this finding?
- A. The client delivered a large baby
- B. She is a gravida 6, para 5
- C. The client had a cesarean delivery
- D. The client had a prolonged labor
Correct Answer: B
Rationale: A client with a higher gravida and para count is at greater risk for uterine atony, which can lead to postpartum hemorrhage. The uterus may be less effective at contracting after multiple pregnancies, causing increased vaginal bleeding. Choices A, C, and D are incorrect because delivering a large baby, having a cesarean delivery, or experiencing prolonged labor do not directly correlate with an increased risk of postpartum hemorrhage in a multigravida client as compared to the gravida and para count.
A client with a head injury reports severe nausea. What is the nurse's priority action?
- A. Administer anti-nausea medication as prescribed.
- B. Prepare the client for a CT scan.
- C. Elevate the head of the bed and provide an emesis basin.
- D. Notify the healthcare provider immediately.
Correct Answer: D
Rationale: Severe nausea in a client with a head injury may be a sign of increased intracranial pressure. The nurse should notify the healthcare provider immediately to ensure timely intervention, as increased pressure can lead to further complications such as brain herniation. Administering anti-nausea medication or preparing for a CT scan may delay necessary treatment for the underlying cause of the nausea, which could be related to the head injury. Elevating the head of the bed and providing an emesis basin may help manage symptoms but should not be the priority over addressing the potential increase in intracranial pressure.
Which information is a priority for the RN to reinforce to an older client after intravenous pyelography?
- A. Eat a light diet for the remainder of the day
- B. Rest for the next 24 hours as the preparation and the test are tiring
- C. Drink at least 1 8-ounce glass of fluid every waking hour for the next 2 days
- D. Measure the urine output for the next day and promptly notify the healthcare provider if it decreases
Correct Answer: D
Rationale: After intravenous pyelography, it is crucial for the client to measure urine output in the next day to monitor for any potential complications, such as kidney issues. Promptly notifying the healthcare provider in case of decreased urine output is essential for timely intervention. While rest and hydration are important post-procedure, monitoring urine output takes precedence due to its direct correlation with potential complications.