Nokea
A client with active tuberculosis (TB) is receiving isoniazid (INH) and rifampin (RMP) daily, so direct observation therapy (DOT) is initiated while the client is hospitalized. Which instruction should the nurse provide this client?
- A. Describe feelings about taking daily medications
- B. Take medications in the presence of the nurse
- C. Notify the nurse after self-medication is completed
- D. Keep a daily record of all medications taken
Correct Answer: B
Rationale: The correct instruction for the nurse to provide the client undergoing direct observation therapy for TB is to take medications in the presence of the nurse. This approach ensures that the client is actually taking the medications as prescribed, reducing the risk of noncompliance. Choice A is incorrect because the focus should be on ensuring the client physically takes the medications rather than discussing feelings. Choice C is incorrect as it does not ensure direct observation. Choice D is incorrect because self-reporting or keeping a record does not guarantee that the client is actually taking the medications.
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A newborn whose mother is HIV positive is admitted to the nursery from labor and delivery. Which action should the nurse implement first?
- A. Initiate treatment with zidovudine (ZDV) syrup at 2 mg per kg
- B. Bathe the infant with dilute chlorhexidine (Hibiclens) or soap
- C. Measure and record the infant's frontal-occipital circumference
- D. Administer vitamin K (AquaMEPHYTON) IM in the vastus lateralis
Correct Answer: B
Rationale: The correct first action for a newborn potentially exposed to HIV is to bathe the infant with dilute chlorhexidine or soap. This helps reduce the risk of infection. Initiating treatment with zidovudine would be important but not the first priority. Measuring and recording the infant's frontal-occipital circumference and administering vitamin K are important tasks but are not the priority when dealing with potential HIV exposure. Immediate hygiene measures are crucial to minimize the risk of transmission.
The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client's plan of care?
- A. Record urine output every hour
- B. Monitor blood pressure frequently
- C. Evaluate neurological status
- D. Maintain seizure precautions
Correct Answer: B
Rationale: Pheochromocytoma is associated with severe hypertension due to excessive catecholamine release. Monitoring blood pressure frequently is the priority intervention to assess for hypertensive crises and prevent complications like stroke, heart attack, or organ damage. While recording urine output every hour, evaluating neurological status, and maintaining seizure precautions are important aspects of care, they are not the highest priority in a client with pheochromocytoma.
After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication?
- A. Ask the client about gastrointestinal pain
- B. Measure the client's fluid intake and output
- C. Monitor the client's serum electrolyte levels
- D. Auscultate for bowel sounds in all quadrants
Correct Answer: A
Rationale: The correct answer is A: Ask the client about gastrointestinal pain. The effectiveness of a proton pump inhibitor (PPI) is best evaluated by assessing the relief of gastrointestinal symptoms, such as heartburn, acid reflux, or stomach pain. These medications work by reducing the production of stomach acid, so improvement in these symptoms indicates the effectiveness of the PPI. Choices B, C, and D are incorrect because they do not directly reflect the effectiveness of a PPI. Measuring fluid intake and output, monitoring serum electrolyte levels, and auscultating for bowel sounds are important for assessing hydration status, electrolyte balance, and gastrointestinal motility, respectively. However, they are not specific to evaluating PPI effectiveness.
A client with a severe prostatic infection that caused a blocked urethra is 3 days post-surgical urinary diversion. The healthcare provider directs the nurse to remove the suprapubic catheter to allow the client to void normally. Which intervention should the nurse implement first?
- A. Cleanse the site around the catheter
- B. Use a 20 ml syringe to deflate balloon
- C. Clamp catheter until the client voids naturally
- D. Empty urine from the urinary drainage bag
Correct Answer: B
Rationale: The correct answer is to use a 20 ml syringe to deflate the balloon first when removing a suprapubic catheter. This step is essential to ensure the safe removal of the catheter without causing any harm or discomfort to the client. Deflating the balloon allows for the catheter to be easily removed. Option A, cleansing the site around the catheter, is not the initial step in this process and can be done after catheter removal. Option C, clamping the catheter until the client voids naturally, is incorrect as it can lead to complications like urinary retention. Option D, emptying urine from the urinary drainage bag, is not the first step in removing the suprapubic catheter and does not address the need to deflate the balloon for safe removal.
At 1130, the nurse assumes care of an adult client with diabetes mellitus who was admitted with an infected foot ulcer. After reviewing the client's electronic health record, which priority nursing action should the nurse implement?
- A. Administer insulin based on the sliding scale
- B. Assess the appearance of the foot wound
- C. Obtain antibiotic peak and trough levels
- D. Initiate hourly measurements of urine output
Correct Answer: B
Rationale: Assessing the appearance of the foot wound is the priority action in this scenario. This assessment is crucial to monitor for any signs of infection progression or complications related to the foot ulcer, especially in a client with diabetes mellitus. Administering insulin based on the sliding scale (Choice A) is important but not the immediate priority compared to assessing the foot wound. Obtaining antibiotic peak and trough levels (Choice C) is relevant but not as immediate as assessing the wound for signs of infection. Initiating hourly measurements of urine output (Choice D) is not the priority when compared to assessing the foot wound in a client with an infected foot ulcer.