Nokea
A client with a severe head injury is admitted to the intensive care unit (ICU). Which finding should the nurse report to the healthcare provider immediately?
- A. Urine output of 100 mL/hour.
- B. Intracranial pressure (ICP) of 20 mm Hg.
- C. Respiratory rate of 12 breaths/minute.
- D. Mean arterial pressure (MAP) of 70 mm Hg.
Correct Answer: B
Rationale: The correct answer is B: Intracranial pressure (ICP) of 20 mm Hg. Elevated ICP can lead to increased intracranial pressure, which can further damage brain tissue and impair cerebral perfusion. This is a critical finding that requires immediate intervention to prevent further brain damage.
A: Urine output of 100 mL/hour is within the normal range and does not pose an immediate threat to the client's condition.
C: Respiratory rate of 12 breaths/minute is within normal limits and does not indicate an immediate concern.
D: Mean arterial pressure (MAP) of 70 mm Hg is within the normal range for most adults and does not require immediate intervention in this scenario.
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The client has acute kidney injury (AKI). Which assessment finding requires immediate intervention?
- A. Urine output of 50 ml in the last hour.
- B. Serum potassium of 6.2 mEq/L.
- C. Blood pressure of 150/90 mm Hg.
- D. Serum creatinine of 2.5 mg/dL.
Correct Answer: B
Rationale: The correct answer is B: Serum potassium of 6.2 mEq/L. Hyperkalemia is a life-threatening condition in AKI. High potassium levels can lead to cardiac arrhythmias and must be addressed immediately. Choice A is concerning but not as critical as hyperkalemia. Choice C, elevated blood pressure, needs monitoring but does not require immediate intervention. Choice D, elevated serum creatinine, indicates kidney dysfunction but does not pose an immediate threat compared to hyperkalemia.
A male client is admitted to the neurological unit. He has just sustained a C-5 spinal cord injury. Which assessment finding of this client warrants immediate intervention by the nurse?
- A. Is unable to feel sensation in the arms and hands.
- B. Has flaccid upper and lower extremities.
- C. Blood pressure is 110/70 and the apical pulse is 68.
- D. Respirations are shallow, labored, and 14 breaths/minute.
Correct Answer: D
Rationale: The correct answer is D because shallow, labored respirations at 14 breaths/minute indicate potential respiratory distress in a client with a C-5 spinal cord injury. This level of injury compromises the function of the diaphragm and intercostal muscles, leading to impaired respiratory effort. Immediate intervention is crucial to prevent respiratory failure and subsequent complications. Choices A and B are common findings in clients with spinal cord injuries and do not require immediate intervention. Choice C indicates stable vital signs within normal range, which do not necessitate immediate action.
A client is admitted with suspected meningitis. Which assessment finding requires immediate intervention?
- A. Headache.
- B. Fever.
- C. Nuchal rigidity.
- D. Seizures.
Correct Answer: D
Rationale: The correct answer is D: Seizures. Seizures in a patient with suspected meningitis indicate increased intracranial pressure, which is a medical emergency requiring immediate intervention to prevent brain damage or herniation. Headache (A), fever (B), and nuchal rigidity (C) are common symptoms of meningitis but do not pose an immediate threat to life like seizures do. Addressing the seizures first is crucial to prevent further complications and ensure the patient's safety.
What action should the healthcare provider take to reduce the risk of vesicant extravasation in a client receiving intravenous chemotherapy?
- A. Administer an antiemetic before starting the chemotherapy.
- B. Instruct the client to drink plenty of fluids during the treatment.
- C. Keep the head of the bed elevated until the treatment is completed.
- D. Monitor the client's intravenous site hourly during the treatment.
Correct Answer: D
Rationale: The correct answer is D: Monitor the client's intravenous site hourly during the treatment. This is crucial to reduce the risk of vesicant extravasation, which can cause tissue damage if the chemotherapy leaks into the surrounding tissues. By monitoring the IV site hourly, the healthcare provider can detect any signs of infiltration or extravasation early and take necessary actions to prevent further harm.
A: Administering an antiemetic before starting chemotherapy is unrelated to preventing vesicant extravasation.
B: Instructing the client to drink plenty of fluids does not directly address the risk of vesicant extravasation.
C: Keeping the head of the bed elevated is not specific to preventing vesicant extravasation and may not effectively reduce the risk.
A client who has Type 1 diabetes and is at 10-weeks gestation comes to the prenatal clinic complaining of a headache, nausea, sweating, feeling shaky, and being tired all the time. What action should the nurse take first?
- A. Check the blood glucose level.
- B. Draw blood for a Hemoglobin A1C.
- C. Assess urine for ketone levels.
- D. Provide the client with a protein snack.
Correct Answer: A
Rationale: The correct answer is A: Check the blood glucose level. This is the first action the nurse should take because the client is presenting with symptoms of hypoglycemia, which can be life-threatening for a pregnant woman with Type 1 diabetes. By checking the blood glucose level, the nurse can determine if the client's symptoms are due to low blood sugar levels and take appropriate action. Drawing blood for a Hemoglobin A1C (choice B) is not the first priority in this acute situation. Assessing urine for ketone levels (choice C) is important in managing diabetes but is not the priority when the client is showing signs of hypoglycemia. Providing the client with a protein snack (choice D) may help raise blood sugar levels, but checking the blood glucose level is essential to determine the appropriate intervention.