Nokea
A client with a urinary tract infection (UTI) is prescribed antibiotics. What is the most important instruction for the nurse to give the client?
- A. Take the antibiotics with food
- B. Complete the full course of antibiotics
- C. Increase fluid intake to at least 2 liters per day
- D. Take over-the-counter pain relievers for discomfort
Correct Answer: B
Rationale: The most crucial instruction for the nurse to give a client with a UTI who is prescribed antibiotics is to complete the full course of antibiotics. Completing the full course of antibiotics is essential to ensure that the infection is fully treated and to prevent the development of antibiotic resistance. While taking antibiotics with food, increasing fluid intake, and managing discomfort with pain relievers are important aspects of UTI management, completing the prescribed course of antibiotics is the top priority to achieve the best treatment outcomes and prevent recurrence of the infection.
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A client is scheduled for surgery in the morning and is NPO. Which statement indicates that the client understands the reason for being NPO?
- A. Being NPO helps reduce the risk of nausea.
- B. I should not eat or drink anything to prevent complications during surgery.
- C. NPO reduces the risk of aspiration during surgery.
- D. NPO helps ensure the stomach is empty during surgery.
Correct Answer: C
Rationale: The correct answer is C: 'NPO reduces the risk of aspiration during surgery.' When a client is NPO (nothing by mouth) before surgery, it is to prevent aspiration, which can lead to serious complications such as pneumonia. Choice A is incorrect because being NPO is more about preventing aspiration than nausea. Choice B is a general statement without specifying the reason for being NPO. Choice D is partially correct but does not emphasize the crucial aspect of preventing aspiration, which is the primary reason for fasting before surgery.
A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is?
- A. Difference in the intake and output
- B. Changes in the mucous membranes
- C. Skin turgor
- D. Weekly weight
Correct Answer: D
Rationale: In clients with altered renal function being treated at home, weekly weight is the most accurate indicator of fluid balance. Fluid retention or loss can significantly affect weight, making it a reliable measure. Choices A, B, and C are not as accurate indicators of fluid balance as weekly weight. Intake and output differences can vary in accuracy and may not capture all aspects of fluid balance. Changes in mucous membranes and skin turgor can be influenced by factors other than fluid balance, making them less precise indicators.
A client receiving heparin therapy develops sudden chest pain and dyspnea. What should the nurse do first?
- A. Administer oxygen and elevate the head of the bed.
- B. Administer sublingual nitroglycerin as prescribed.
- C. Assess for signs of bleeding at the injection site.
- D. Administer a PRN dose of albuterol.
Correct Answer: A
Rationale: In this scenario, the priority action for the nurse is to administer oxygen and elevate the head of the bed. These interventions help relieve dyspnea and chest pain, which can be indicative of a pulmonary embolism or other complications during heparin therapy. Administering nitroglycerin (Choice B) is not the initial priority in this situation as the client's symptoms are not suggestive of angina. Assessing for bleeding (Choice C) is important but not the first action needed to address chest pain and dyspnea. Administering albuterol (Choice D) is not indicated unless there are specific respiratory issues requiring it, which are not described in the scenario.
During the admission assessment of a 3-year-old with bacterial meningitis and hydrocephalus, which assessment finding is evidence of increased intracranial pressure (ICP)?
- A. Low blood pressure
- B. Increased respiratory rate
- C. Normal pupil reaction
- D. Sluggish and unequal pupillary responses
Correct Answer: D
Rationale: Sluggish and unequal pupillary responses are indicative of increased intracranial pressure (ICP) in a child with bacterial meningitis and hydrocephalus. This finding suggests that the optic nerve is being compressed due to increased ICP, causing a delay in pupillary reactions. Such a delay is a critical sign of worsening ICP and necessitates immediate intervention. Low blood pressure and increased respiratory rate can occur in various conditions but are less specific to increased ICP than sluggish and unequal pupillary responses, which directly reflect neurological compromise.
A client with hyperkalemia is receiving insulin and glucose. Which laboratory value should the nurse monitor closely?
- A. Monitor the client's blood glucose level.
- B. Monitor the client's sodium level.
- C. Monitor the client's calcium level.
- D. Monitor the client's potassium level.
Correct Answer: D
Rationale: The correct answer is to monitor the client's potassium level. When administering insulin and glucose in hyperkalemia, the aim is to shift potassium from the bloodstream into the cells, lowering elevated levels. Therefore, monitoring potassium levels closely is essential to prevent hypokalemia or further complications. Monitoring blood glucose levels (Choice A) is important but not the priority in this scenario. Monitoring sodium (Choice B) and calcium levels (Choice C) is not directly related to the treatment of hyperkalemia with insulin and glucose.