Nokea
A client with a history of severe rheumatoid arthritis is receiving a corticosteroid. Which assessment finding should the nurse report to the healthcare provider immediately?
- A. Blood glucose level of 180 mg/dL
- B. Weight gain of 2 pounds in 24 hours
- C. Blood pressure of 140/90 mmHg
- D. Increased joint pain
Correct Answer: C
Rationale: Elevated blood pressure (140/90 mmHg) is a significant finding that the nurse should report immediately. Hypertension can be a severe side effect of corticosteroid therapy, especially in clients with preexisting conditions like rheumatoid arthritis. It requires prompt intervention to prevent complications such as cardiovascular events. The other options, while important to monitor, are not as critical as elevated blood pressure in this context. A blood glucose level of 180 mg/dL may indicate hyperglycemia, weight gain could be due to fluid retention, and increased joint pain is expected in a client with severe rheumatoid arthritis.
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To reduce staff nurse role ambiguity, which strategy should the nurse-manager implement?
- A. Review the staff nurse job description to ensure that it is clear, accurate, and current.
- B. Conduct regular meetings to clarify roles.
- C. Increase communication between team members.
- D. Provide additional training for new nurses.
Correct Answer: A
Rationale: The correct answer is A: Review the staff nurse job description to ensure that it is clear, accurate, and current. By ensuring that job descriptions are clear and up-to-date, nurse-managers can reduce ambiguity and confusion about roles and responsibilities. Choice B, conducting regular meetings to clarify roles, may help but may not address the root cause of ambiguity. Choice C, increasing communication between team members, is important but may not specifically target role ambiguity. Choice D, providing additional training for new nurses, is valuable but may not directly address role ambiguity among existing staff.
A client with a history of atrial fibrillation is receiving warfarin (Coumadin). Which assessment finding is most concerning?
- A. INR of 3.5
- B. Prothrombin time (PT) of 15 seconds
- C. Headache
- D. Blood pressure of 140/90 mmHg
Correct Answer: C
Rationale: The correct answer is C. A headache in a client with a history of atrial fibrillation receiving warfarin (Coumadin) is concerning as it may indicate bleeding, which requires immediate assessment and intervention. Headaches can be a symptom of increased intracranial pressure due to bleeding, especially in patients on anticoagulants. Options A and B are within acceptable ranges for a client on warfarin therapy, indicating that the medication is effectively managing the clotting times. Option D, a blood pressure of 140/90 mmHg, while elevated, is not directly related to the client's condition of atrial fibrillation and warfarin therapy.
The nurse enters a client's room and observes the unlicensed assistive personnel (UAP) making an occupied bed. What action should the nurse take first?
- A. Place the side rails in an up position.
- B. Assist the UAP in turning the client.
- C. Provide instructions on proper bed-making techniques.
- D. Ask the client if they are comfortable.
Correct Answer: A
Rationale: The correct answer is to place the side rails in an up position first. This action is essential to prevent the client from falling while the bed is being made. Assisting the UAP in turning the client (Choice B) is not the immediate priority. Providing instructions on bed-making techniques (Choice C) can wait until the safety of the client is ensured. Asking the client if they are comfortable (Choice D) is important but should come after ensuring the client's safety by raising the side rails.
A nurse is caring for a client with Diabetes Insipidus. Which assessment finding warrants immediate intervention by the nurse?
- A. Hypernatremia
- B. Excessive thirst
- C. Elevated heart rate
- D. Poor skin turgor
Correct Answer: A
Rationale: The correct answer is A: Hypernatremia. In a client with Diabetes Insipidus, hypernatremia, an elevated sodium level in the blood, can lead to neurological symptoms such as confusion, seizures, or coma. Immediate intervention is necessary to prevent these serious complications. Excessive thirst (choice B) is a common symptom of Diabetes Insipidus but does not require immediate intervention. Elevated heart rate (choice C) and poor skin turgor (choice D) are important assessments but are not as critical as hypernatremia in this context.
A client with gestational diabetes, at 39 weeks of gestation, is in the second stage of labor. After delivering the fetal head, the nurse recognizes that shoulder dystocia is occurring. What intervention should the nurse implement first?
- A. Prepare the client for an emergency cesarean birth
- B. Encourage the client to move to a hands-and-knees position
- C. Assist the client to sharply flex her thighs up against the abdomen
- D. Lower the head of the bed and apply suprapubic pressure
Correct Answer: C
Rationale: In cases of shoulder dystocia, the priority intervention is to assist the client in sharply flexing her thighs up against the abdomen (McRoberts maneuver). This action helps to widen the pelvic outlet. Encouraging the client to move to a hands-and-knees position may also be beneficial in some cases but is not the first-line intervention. Preparing for an emergency cesarean birth and applying suprapubic pressure are not appropriate initial interventions for shoulder dystocia.