Nokea
A client with Addison's disease is admitted to the medical unit. The nurse diagnoses the client with Deficient fluid volume related to inadequate fluid intake and to fluid loss secondary to inadequate adrenal hormone secretion. As the client's oral intake increases, which of the following fluids would be most appropriate?
- A. Milk and diet soda.
- B. Water and eggnog.
- C. Bouillon and juice.
- D. Coffee and milkshakes.
Correct Answer: C
Rationale: Bouillon provides sodium, and juice offers hydration and calories, supporting fluid and electrolyte balance in Addison's disease.
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A client returned to the recovery room after a dilatation and curettage has the postoperative medication orders shown in the chart. What should the nurse do next?
- A. Ask the client to rate the intensity of her painon a scale of 1 to 10 and administer the analgesia according to the intensity of the pain.
- B. Administer the Demerol fi rst because the client had surgery today.
- C. Administer the Tylenol #3 fi rst, and if it does not relieve the pain in 2 hours, administer the Demerol.
- D. Administer the Motrin fi rst and if it does not relieve the pain, administer the Demerol.
Correct Answer: A
Rationale: The nurse must fi rst assess the intensity of the client’s pain before selecting the correct analgesia. A high score would necessitate administering the meperidine (Demerol). If the intensity rating is low, an oral analgesic would be appropriate. If acetaminophen (Tylenol #3) is given without assessing the intensity of the client’s pain, the nurse must then wait 4 hours before administering another analgesic
The nurse in the emergency department (ED) is caring for a 62-year-old male client.
Item 6 of 6
Triage Note
1700:
• The client was brought to the ED after collapsing on a tennis court.
• Vital signs: BP 94/57, T 105° F (40.5° C), P 115, RR 26, Pulse oximetry 95% on room air. • The client is lethargic and confused. Skin is pale, and there is some perspiration on the forehead. Thready peripheral pulses, clear lung fields bilaterally, tachypnea, shallow respirations.
Which two (2) findings in the nurses' note would require immediate follow-up and reported to the physician?
- A. Rectal temperature
- B. Generalized shivering
- C. Urine output
- D. Assessment of the peripheral pulses
- E. Client reports of thirst
Correct Answer: B,C
Rationale: Generalized shivering may indicate worsening hypothermia or a cooling blanket complication, and low urine output suggests renal hypoperfusion or acute kidney injury, both requiring immediate physician notification. Temperature (A), pulses (D), and thirst (E) are expected or less urgent.
Which safety measures would be most important to implement when caring for a client who is receiving 2 units of packed red blood cells (PRBCs)? Select all that apply.
- A. Verify that the ABO and Rh of the 2 units are the same.
- B. Infuse the unit of PRBCs in less than 4 hours.
- C. Stop the transfusion if a reaction occurs, but keep the line open.
- D. Take vital signs every 15 minutes while the unit is transfusing.
- E. Inspect the blood bag for leaks, abnormal color, and clots.
- F. Use a 22-gauge catheter for optimal flow of a blood transfusion.
Correct Answer: A,B,C,E
Rationale: Key safety measures for PRBC transfusion include verifying ABO and Rh compatibility to prevent reactions, infusing within 4 hours to reduce infection risk, stopping the transfusion if a reaction occurs while keeping the line open, and inspecting the blood bag for abnormalities. Taking vital signs every 15 minutes is excessive (typically every 15 minutes for the first 15 minutes, then hourly). A 22-gauge catheter is too small; a larger gauge (18–20) is needed for optimal flow.
The nurse is to administer an antibiotic to a client with burns now, but there is no medication in the client's medication box. What should the nurse do first?
- A. Inform the unit's shift coordinator.
- B. Contact the client's physician.
- C. Call the pharmacy department.
- D. Borrow the medication from another client.
Correct Answer: C
Rationale: Calling the pharmacy ensures timely delivery of the correct medication, maintaining safety and adherence to protocol. Borrowing medication is unsafe and unethical.
The nurse is assessing a client who has a chest tube connected to a water-seal chest tube drainage system. According to the illustrationshown, which should the nurse do?
- A. Clamp the chest tube near the insertion site to prevent air from entering the pleural cavity.
- B. Notify the physician of the amount of chest tube drainage.
- C. Add water to maintain the water seal.
- D. Lower the drainage system to maintain gravity flow.
Correct Answer: D
Rationale: To promote chest tube drainage the drainage system must be lower than the client's lungs. The amount of drainage is not abnormal; it is not necessary to notify the physician. The nurse should chart the amount and color of drainage every 4 to 8 hours.