Nokea
A client with acute pancreatitis is receiving intravenous fluids and pain medication. What is the priority assessment for this client?
- A. Monitor bowel sounds
- B. Measure urine output
- C. Assess for abdominal tenderness
- D. Monitor blood glucose levels
Correct Answer: D
Rationale: The correct answer is D: Monitor blood glucose levels. Clients with acute pancreatitis are prone to hyperglycemia due to impaired insulin production. Monitoring blood glucose levels is crucial to prevent complications like diabetic ketoacidosis. While assessing bowel sounds, urine output, and abdominal tenderness are important in the overall care of a client with acute pancreatitis, monitoring blood glucose levels takes priority to address the immediate risk of hyperglycemia.
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A client with end-stage pulmonary disease requests 'no heroic measures' if she stops breathing. What should the nurse do next?
- A. Document the client's request in the medical record.
- B. Ask the client to discuss a DNR order with her healthcare provider.
- C. Consult the ethics committee for guidance.
- D. Discharge the client with no further discussion.
Correct Answer: B
Rationale: The correct next step for the nurse is to ask the client to discuss a 'do not resuscitate' (DNR) order with her healthcare provider. While the client's wishes should be respected, it is essential to ensure proper documentation and legal protection by involving the healthcare provider in this decision-making process. Documenting the request in the medical record (Choice A) is important but should follow the discussion with the healthcare provider. Consulting the ethics committee (Choice C) may not be necessary at this stage and could delay the necessary actions. Discharging the client (Choice D) without further discussion is not appropriate and disregards the importance of addressing the client's wishes in a respectful and professional manner.
The nurse is providing care for a client receiving total parenteral nutrition (TPN). Which action should the nurse include in the client's plan of care?
- A. Increase the TPN infusion rate if the client is hungry
- B. Administer TPN via a peripheral IV line
- C. Monitor blood glucose levels regularly
- D. Ensure the TPN solution is refrigerated at all times
Correct Answer: C
Rationale: The correct action the nurse should include in the client's plan of care is to monitor blood glucose levels regularly. Clients receiving TPN are at risk for hyperglycemia due to the high glucose content of the solution. Regular monitoring of blood glucose levels is essential to ensure appropriate management of blood sugar. Choice A is incorrect because increasing the TPN infusion rate based on hunger is not a valid parameter for adjusting TPN. Choice B is incorrect because TPN should be administered through a central line, not a peripheral IV line, to prevent complications. Choice D is incorrect because TPN solutions should be stored at room temperature, not refrigerated.
A client with a fractured femur is placed in skeletal traction. What action should the nurse prioritize?
- A. Ensure that the weights are freely hanging.
- B. Place pillows under the client's knees.
- C. Adjust the weights to alleviate discomfort.
- D. Ensure that the traction ropes are free of knots.
Correct Answer: A
Rationale: The correct action the nurse should prioritize when a client is placed in skeletal traction for a fractured femur is to ensure that the weights are freely hanging. This is crucial to maintain proper alignment of the bone and prevent complications. Placing pillows under the client's knees (Choice B) is not a priority in skeletal traction. Adjusting the weights to alleviate discomfort (Choice C) should not be done without proper orders from the healthcare provider. Ensuring that the traction ropes are free of knots (Choice D) is important but ensuring the weights hang freely is the priority to maintain traction effectiveness.
After a lumbar puncture, a client reports a severe headache. What is the nurse's priority intervention?
- A. Administer a dose of acetaminophen.
- B. Elevate the head of the bed.
- C. Encourage the client to rest in a dark room.
- D. Administer caffeine to relieve the headache.
Correct Answer: B
Rationale: After a lumbar puncture, a severe headache is often caused by cerebrospinal fluid leakage. Elevating the head of the bed or having the client lie flat can reduce cerebrospinal fluid pressure and alleviate the headache. These positions help prevent further fluid loss and relieve discomfort. While acetaminophen or caffeine may help in relieving the headache, changing the client's position is the priority to address the underlying cause. Resting in a dark room may be beneficial for headache relief but is not the priority intervention compared to adjusting the position to manage cerebrospinal fluid pressure.
The client is being taught about precautions with Coumadin therapy. The client should be instructed to avoid which over-the-counter medication?
- A. Non-steroidal anti-inflammatory drugs
- B. Cough medicines containing guaifenesin
- C. Histamine blockers
- D. Laxatives containing magnesium salts
Correct Answer: A
Rationale: The correct answer is A: Non-steroidal anti-inflammatory drugs (NSAIDs). NSAIDs can increase the risk of bleeding in clients taking Coumadin, which is an anticoagulant medication. Avoiding NSAIDs helps prevent potentially dangerous interactions with Coumadin. Choices B, C, and D are incorrect. Cough medicines with guaifenesin, histamine blockers, and laxatives containing magnesium salts do not typically have significant interactions with Coumadin therapy. Therefore, they are not the over-the-counter medications that the client needs to avoid while on Coumadin.