Nokea
A client with antisocial personality disorder repeatedly requests a specific nurse be assigned to him and is belligerent when another nurse is assigned. What action should the charge nurse implement?
- A. Remind the client that nurse assignments are not based on patient requests
- B. Assign the nurse requested by the client to avoid further conflict
- C. Tell the client that he can request a different nurse if unhappy
- D. Explain the situation calmly and reinforce the rules regarding nurse assignments
Correct Answer: A
Rationale: The correct action for the charge nurse to implement is to remind the client that nurse assignments are not based on patient requests. In this situation, it is essential to establish boundaries and communicate that nurse assignments are made based on clinical decisions, not patient preferences. Option B is incorrect because it compromises the principle of fairness in nurse assignments. Option C is incorrect as it encourages the client's behavior by allowing him to request a different nurse based on personal preferences. Option D is also incorrect as it does not address the issue of patient manipulation and reinforces inappropriate behavior.
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An older adult client with chronic emphysema is admitted with acute onset of weakness, palpitation, and vomiting. Which information is most important for the nurse to obtain during the initial interview?
- A. Medication compliance over the past few weeks.
- B. Recent sleep patterns and rest.
- C. Recent history of smoking.
- D. Activity level prior to symptom onset.
Correct Answer: A
Rationale: The correct answer is A: Medication compliance over the past few weeks. In a client with chronic emphysema experiencing acute symptoms, it is crucial to assess medication compliance as it directly impacts symptom control and disease management. Ensuring the client has been adherent to their prescribed medications can provide insights into potential exacerbating factors or the need for adjustments in the treatment plan. Choices B, C, and D are less critical during the initial assessment compared to medication compliance. Recent sleep patterns and rest (choice B) may be relevant but are secondary to ensuring proper medication management. While smoking history (choice C) is important in chronic lung conditions, the immediate focus should be on the current status of medication use. Activity level prior to symptom onset (choice D) is also pertinent but not as crucial as confirming medication compliance to address the acute symptoms.
Which medication should the nurse withhold if the client's serum potassium level is 6.2 mEq/L?
- A. Losartan
- B. Spironolactone
- C. Metoprolol
- D. Furosemide
Correct Answer: B
Rationale: The correct answer is B: Spironolactone. Spironolactone is a potassium-sparing diuretic that can lead to hyperkalemia. With potassium levels already elevated at 6.2 mEq/L, withholding Spironolactone is essential to prevent further increase in potassium levels, which could result in dangerous cardiac arrhythmias. Losartan (Choice A) is an angiotensin receptor blocker and does not directly affect potassium levels. Metoprolol (Choice C) is a beta-blocker and also does not impact potassium levels significantly. Furosemide (Choice D) is a loop diuretic that can actually lower potassium levels, so it would not be the medication to withhold in this case.
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 66-year-old woman is retiring and needs health insurance. To which agency should the employee health nurse refer her?
- A. Medicaid
- B. Medicare
- C. COBRA
- D. Private insurance
Correct Answer: B
Rationale: The correct answer is B: Medicare. Medicare is the federal health insurance program for individuals aged 65 and older, so it is the most suitable option for the 66-year-old woman retiring. Medicaid (choice A) is a state and federally funded program for low-income individuals and families, not specifically for retirees. COBRA (choice C) allows employees to continue their employer-sponsored health insurance for a limited time after leaving employment. Private insurance (choice D) refers to health insurance plans purchased directly from private insurance companies.
When assessing an IV site used for fluid replacement and medication administration, the client complains of tenderness when the arm is touched above the site. Which additional assessment finding warrants immediate intervention by the nurse?
- A. Cool skin at the IV insertion site
- B. Presence of fluid leaking around the IV catheter
- C. Swelling above the IV site
- D. Red streaks tracking the vein
Correct Answer: D
Rationale: The correct answer is D: "Red streaks tracking the vein." Red streaks indicate phlebitis, an inflammation of the vein that can lead to serious complications like infection or thrombophlebitis. Immediate intervention is required to prevent further damage. Choice A, cool skin at the IV insertion site, could indicate decreased circulation but is not as urgent as addressing phlebitis. Choice B, presence of fluid leaking around the IV catheter, may indicate infiltration or dislodgement of the catheter, requiring intervention but not as urgently as phlebitis. Choice C, swelling above the IV site, may suggest localized inflammation but doesn't pose an immediate threat like phlebitis does.