Nokea
A client with Addison's disease becomes confused and weak. What is the nurse's first action?
- A. Administer a dose of hydrocortisone immediately.
- B. Check the client's electrolyte levels.
- C. Administer a dose of normal saline.
- D. Measure the client's blood pressure in both arms.
Correct Answer: A
Rationale: The correct answer is to administer a dose of hydrocortisone immediately. In Addison's disease, confusion and weakness can be signs of an adrenal crisis. Administering hydrocortisone promptly is crucial to prevent further deterioration. Checking electrolyte levels (Choice B) is important but not the first action in managing an acute adrenal crisis. Administering normal saline (Choice C) is not the priority in this situation. Measuring blood pressure in both arms (Choice D) is not the initial action needed to address the client's confusion and weakness in Addison's disease.
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The nurse is caring for a client who has COPD and chest pain related to a recent fall. What nursing intervention requires the greatest caution when caring for a client with COPD?
- A. Administering narcotics for pain relief
- B. Encouraging the client to increase fluid intake
- C. Applying oxygen therapy at a high flow rate
- D. Assisting the client with deep breathing exercises
Correct Answer: C
Rationale: The correct answer is C: Applying oxygen therapy at a high flow rate. In clients with COPD, high levels of supplemental oxygen can suppress the hypoxic drive to breathe, leading to carbon dioxide retention and respiratory depression. Oxygen therapy must be administered cautiously to prevent worsening respiratory status. Administering narcotics for pain relief (Choice A) can be necessary but should be done judiciously. Encouraging fluid intake (Choice B) and assisting with deep breathing exercises (Choice D) are generally beneficial interventions for clients with COPD and should not require the same level of caution as high-flow oxygen therapy.
The nursing student is discussing with a preceptor the delegation of tasks to an unlicensed assistive personnel (UAP). Which tasks, delegated to a UAP, indicates the student needs further teaching about the delegation process?
- A. Assist a client post cerebral vascular accident to ambulate
- B. Feed a 2-year-old in balanced skeletal traction
- C. Care for a client with discharge orders
- D. Collect a sputum specimen for acid-fast bacillus
Correct Answer: C
Rationale: Caring for a client with discharge orders involves tasks that require critical thinking and clinical judgment, which are beyond the scope of a UAP. Delegating this task to a UAP can compromise patient safety and outcomes. The correct answer is C. Choices A, B, and D are appropriate tasks to delegate to a UAP based on their training and scope of practice. Assisting a client to ambulate, feeding a pediatric patient in traction, and collecting a sputum specimen are tasks that can be safely performed by a UAP under appropriate supervision.
A client with a venous leg ulcer is receiving compression therapy. What assessment finding requires immediate intervention?
- A. Decreased pain and increased redness around the ulcer.
- B. Increased serous drainage from the ulcer site.
- C. Cool extremities and weak peripheral pulses.
- D. Pitting edema around the ulcer site.
Correct Answer: C
Rationale: The correct answer is C. Cool extremities and weak peripheral pulses indicate compromised circulation, possibly due to inadequate arterial blood supply. This finding requires immediate intervention to prevent further complications such as tissue damage or non-healing ulcers. Option A, decreased pain and increased redness, can be a sign of improving wound condition. Option B, increased serous drainage, may indicate a normal part of the healing process. Option D, pitting edema, is common in venous leg ulcers and may not require immediate intervention unless severe and accompanied by other concerning symptoms.
A client receiving full-strength continuous enteral tube feeding develops diarrhea. What intervention should the nurse take?
- A. Stop the feeding and provide IV fluids.
- B. Dilute the feeding to half strength and continue at the same rate.
- C. Reduce the feeding rate and monitor for improvement.
- D. Add fiber to the client's diet to resolve diarrhea.
Correct Answer: B
Rationale: When a client develops diarrhea from continuous enteral tube feeding, diluting the feeding to half strength and continuing at the same rate is the appropriate intervention. This helps reduce the strength of the feeding, minimizing gastrointestinal upset while still providing necessary nutrition. Stopping the feeding abruptly (Choice A) may lead to nutritional deficits. Simply reducing the feeding rate (Choice C) may not effectively address the issue of diarrhea. Adding fiber (Choice D) could potentially worsen the diarrhea in this scenario instead of resolving it.
A child is admitted with bacterial meningitis. What assessment finding should the nurse monitor most closely?
- A. Monitor the client's skin for rash and lesions.
- B. Monitor for signs of increased intracranial pressure.
- C. Monitor the client's blood pressure closely.
- D. Monitor for changes in heart rate and rhythm.
Correct Answer: B
Rationale: Correct Answer: B. Signs of increased intracranial pressure, such as changes in consciousness or pupil reactivity, are critical to monitor in children with bacterial meningitis to prevent complications. Monitoring the client's skin for rash and lesions (Choice A) is not the priority in bacterial meningitis. While monitoring blood pressure (Choice C) is important, signs of increased intracranial pressure take precedence. Monitoring for changes in heart rate and rhythm (Choice D) is less specific to the condition and may not indicate worsening neurological status.