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A client with asthma is experiencing wheezing. What is the nurse's priority intervention?
- A. Administer a bronchodilator immediately.
- B. Increase the client's oxygen flow rate.
- C. Perform a chest x-ray to assess lung function.
- D. Place the client in a high Fowler's position.
Correct Answer: A
Rationale: The correct answer is A: Administer a bronchodilator immediately. Wheezing in a client with asthma indicates bronchoconstriction, which can compromise airflow. Administering a bronchodilator is the priority intervention as it helps to open the airways, relieve bronchoconstriction, and improve breathing. Increasing the oxygen flow rate (choice B) may be necessary but is not the priority when the airways are constricted. Performing a chest x-ray (choice C) is not the immediate action needed in this situation. Placing the client in a high Fowler's position (choice D) may provide some relief, but administering a bronchodilator to address the bronchoconstriction is the priority intervention.
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A client is receiving a blood transfusion and develops chills and back pain. What is the nurse's first action?
- A. Stop the transfusion and notify the healthcare provider.
- B. Monitor the client's vital signs every 15 minutes.
- C. Administer a PRN dose of diphenhydramine.
- D. Prepare to administer an antihistamine.
Correct Answer: A
Rationale: The correct first action for the nurse is to stop the transfusion and notify the healthcare provider. These symptoms suggest a transfusion reaction, and stopping the transfusion is crucial to prevent further complications. Notifying the healthcare provider ensures timely intervention and appropriate management for the client's condition. Monitoring vital signs, administering diphenhydramine, or preparing to administer an antihistamine can be considered after stopping the transfusion and seeking guidance from the healthcare provider. However, the immediate priority is to halt the transfusion and inform the provider.
A client with cirrhosis is admitted with ascites and peripheral edema. Which intervention should the nurse implement first?
- A. Elevate the legs to reduce swelling.
- B. Restrict fluids to reduce fluid overload.
- C. Administer furosemide to reduce fluid overload.
- D. Monitor the client's intake and output.
Correct Answer: C
Rationale: Administering a diuretic like furosemide is the priority intervention for a client with cirrhosis, ascites, and peripheral edema. Furosemide helps reduce fluid overload by promoting diuresis. Elevating the legs may provide some symptomatic relief but does not address the underlying issue of fluid overload. Restricting fluids is not appropriate initially as the client needs proper hydration while managing fluid balance. Monitoring intake and output is important but not the first action to address the immediate fluid overload in this client.
A client is receiving continuous intravenous heparin for a deep vein thrombosis. Which laboratory result should the nurse monitor to ensure therapeutic heparin levels?
- A. International normalized ratio (INR)
- B. Activated partial thromboplastin time (aPTT)
- C. Hemoglobin
- D. Platelet count
Correct Answer: B
Rationale: The activated partial thromboplastin time (aPTT) is the most accurate measure of heparin's therapeutic effect. Heparin increases the time it takes for blood to clot, and the aPTT helps determine whether the dose is within the desired range for anticoagulation therapy. Monitoring the INR, hemoglobin, or platelet count is not specific to assessing therapeutic heparin levels and may not reflect the anticoagulant effect of heparin.
The nurse is caring for a group of clients with the help of a PN. Which nursing actions should the nurse assign to the PN?
- A. All of the above
- B. Administer a dose of insulin per sliding scale for a client with Type 2 DM
- C. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty
- D. Perform daily surgical dressing change for a client who had an abdominal hysterectomy
Correct Answer: A
Rationale: All of these tasks fall within the PN's scope of practice, which includes performing surgical dressing changes, taking postoperative vital signs, and administering insulin under supervision. The RN can delegate these tasks to the PN safely. Choice A is the correct answer because all the tasks mentioned are appropriate for delegation to a PN. Choice B should not be assigned to a PN as only RNs should administer insulin. Choice C is suitable for delegation to a PN as obtaining vital signs falls within their scope of practice. Choice D is also appropriate for delegation to a PN as performing surgical dressing changes is within their scope of practice.
A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge?
- A. Nutritional guidelines to support blood health
- B. Signs of infection to monitor for
- C. When to give pain medication
- D. Instructions about how much fluid the child should drink daily
Correct Answer: D
Rationale: Proper hydration is crucial in managing sickle cell anemia (SCA) as it helps prevent sickling of red blood cells and reduces blood viscosity, which can lead to painful crises. Ensuring the child drinks enough fluids is essential to maintain adequate hydration levels and reduce the risk of complications. While nutritional guidelines and recognizing signs of infection are important aspects of care, maintaining proper hydration is the most immediate and critical factor in managing SCA and preventing crises.