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A client with cirrhosis develops ascites. What is the nurse's priority intervention?
- A. Administer diuretics as prescribed.
- B. Restrict fluid intake to manage fluid overload.
- C. Position the client in Fowler's position and assess for respiratory distress.
- D. Measure the client's abdominal girth daily.
Correct Answer: B
Rationale: The correct answer is B: Restrict fluid intake to manage fluid overload. In a client with cirrhosis developing ascites, the priority intervention is to restrict fluid intake. This helps manage fluid overload, prevent further complications, such as respiratory distress or kidney impairment, and reduce the accumulation of ascitic fluid. Administering diuretics may be a part of the treatment plan, but the primary focus should be on fluid restriction. Positioning the client in Fowler's position and measuring the abdominal girth are important interventions but not the priority when managing ascites in cirrhosis.
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A client with type 1 diabetes is admitted to the emergency room with abdominal pain, polyuria, and confusion. What should the nurse implement first?
- A. Administer intravenous insulin.
- B. Start an intravenous fluid bolus.
- C. Obtain a blood glucose level.
- D. Administer an antiemetic.
Correct Answer: B
Rationale: In this scenario, the nurse should first start an intravenous fluid bolus. This intervention is crucial in addressing severe dehydration associated with diabetic ketoacidosis, a life-threatening complication of type 1 diabetes. Administering intravenous insulin (Choice A) is important but should follow fluid resuscitation. Obtaining a blood glucose level (Choice C) is necessary but not as urgent as addressing the dehydration. Administering an antiemetic (Choice D) is not the priority in this situation.
A child is brought to the emergency department after ingesting an unknown quantity of acetaminophen. What is the most important action for the nurse to take?
- A. Assess the child's level of consciousness.
- B. Prepare to administer activated charcoal.
- C. Notify the poison control center.
- D. Obtain an order for serum acetaminophen levels.
Correct Answer: D
Rationale: Obtaining serum acetaminophen levels is critical in determining the level of toxicity and guiding treatment. It helps to assess the risk of hepatotoxicity and determine the need for antidotal therapy with N-acetylcysteine. Assessing the child's level of consciousness (Choice A) is important but obtaining serum acetaminophen levels takes precedence as it directly guides the specific treatment required. Activated charcoal (Choice B) is not routinely used in acetaminophen poisoning. While notifying the poison control center (Choice C) is important, obtaining serum acetaminophen levels should be the immediate action to assess the child's condition and guide treatment.
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.
A client with type 1 diabetes is found unconscious with a blood glucose of 40 mg/dL. What is the nurse's priority intervention?
- A. Administer a 50% dextrose bolus intravenously.
- B. Administer glucagon intramuscularly.
- C. Provide oral glucose gel.
- D. Recheck the blood glucose level in 15 minutes.
Correct Answer: A
Rationale: The correct answer is to administer a 50% dextrose bolus intravenously. In unconscious clients with hypoglycemia, IV dextrose rapidly raises the blood glucose level. Glucagon would be a slower option and is typically used if IV access is unavailable. Oral glucose gel is not appropriate for an unconscious client as it requires swallowing and may cause aspiration. Rechecking the blood glucose level in 15 minutes delays immediate treatment and could lead to further deterioration.
A male client with HIV receiving saquinavir PO in combination with other antiretrovirals reports constant hunger and thirst but is losing weight. What action should the nurse implement?
- A. Use a glucometer to check glucose level.
- B. Teach client to measure weight accurately.
- C. Explain that medication dose may need to be increased.
- D. Reassure client weight will increase as viral load decreases.
Correct Answer: A
Rationale: The correct action for the nurse to implement is to use a glucometer to check the client's glucose level. Saquinavir, an HIV medication, can lead to hyperglycemia, which may cause symptoms like constant hunger and thirst while losing weight. Checking the glucose level will help assess for hyperglycemia. Choice B is not the priority in this situation as the client's weight loss is a concerning symptom that needs immediate attention. Choice C is incorrect because increasing the medication dose without assessing the glucose level first could exacerbate hyperglycemia. Choice D is incorrect as it does not address the symptoms of constant hunger, thirst, and weight loss, which may indicate a more urgent issue like hyperglycemia.