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A client with cirrhosis is receiving lactulose. What is the most important assessment for the nurse to monitor?
- A. Monitor the client's ammonia levels.
- B. Monitor the client's blood glucose level.
- C. Monitor the client's potassium levels.
- D. Monitor the client's level of consciousness.
Correct Answer: D
Rationale: The correct answer is to monitor the client's level of consciousness. Lactulose is used to reduce ammonia levels in hepatic encephalopathy. Monitoring the level of consciousness helps assess the effectiveness of lactulose therapy in improving the client's condition. Monitoring ammonia levels (choice A) is important, but assessing the client's response to therapy through their level of consciousness is more crucial. Blood glucose levels (choice B) and potassium levels (choice C) are not directly related to lactulose therapy for cirrhosis and hepatic encephalopathy.
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The healthcare provider is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for immediate action by the healthcare provider?
- A. Breath sounds are audible bilaterally
- B. Mist is visible in the T-piece
- C. Pulse oximetry of 88
- D. Client is unable to verbalize
Correct Answer: C
Rationale: A pulse oximetry reading of 88 indicates hypoxia, which is a serious condition requiring immediate intervention. Adequate oxygenation is crucial for the client's well-being. Choices A and B are normal findings after endotracheal intubation. Hearing bilateral breath sounds and seeing mist in the T-piece indicate proper functioning of the endotracheal tube. While choice D may indicate an issue with speaking due to the endotracheal tube, it is not as critical as the hypoxia indicated by the low pulse oximetry reading.
A client reports that the skin around the edges of a wound is red and swollen. What is the nurse's priority intervention?
- A. Monitor for signs of infection
- B. Reinforce the wound dressing
- C. Contact the healthcare provider
- D. Apply a warm compress to the wound
Correct Answer: A
Rationale: The correct answer is to monitor for signs of infection. Redness and swelling around a wound are indicative of a potential infection. The priority intervention for the nurse is to closely monitor the wound for further signs of infection, such as increased drainage or fever. Reinforcing the wound dressing may be necessary, but it is not the priority when infection is suspected. Contacting the healthcare provider is important, but the nurse should first assess and monitor the wound to provide comprehensive information when contacting the provider. Applying a warm compress can potentially worsen the infection by promoting bacterial growth, so it is contraindicated in this situation.
A client on long-term corticosteroid therapy for rheumatoid arthritis presents with weakness and hypotension. What is the nurse's first action?
- A. Administer a PRN dose of corticosteroids.
- B. Place the client in a supine position.
- C. Encourage oral fluid intake.
- D. Review the client's recent medication history.
Correct Answer: A
Rationale: Administering a PRN dose of corticosteroids is the correct first action when a client on long-term corticosteroid therapy presents with weakness and hypotension. In this scenario, the client is likely experiencing adrenal insufficiency due to prolonged corticosteroid use. Administering corticosteroids promptly can help correct this insufficiency and improve the client's symptoms. Placing the client in a supine position may be necessary for symptomatic hypotension, but addressing the root cause with corticosteroids is more crucial initially. Encouraging oral fluid intake is important for many conditions but is not the priority in this case. Reviewing the client's recent medication history can provide valuable information but is not the first action needed to address the client's current presentation.
A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the room in response to the call. After checking the client's pulse and respirations, what should be the function of the second nurse?
- A. Relieve the nurse performing CPR
- B. Go get the code cart
- C. Participate with the compressions or breathing
- D. Validate the client's advanced directive
Correct Answer: C
Rationale: The correct answer is C. The second nurse should assist with compressions or breathing to ensure the patient receives adequate care during CPR. This immediate intervention is crucial in maintaining blood circulation and oxygenation to vital organs. Choice A is incorrect because simply relieving the nurse performing CPR may lead to a delay in essential life-saving measures. Choice B is incorrect as the primary focus should be on providing direct assistance rather than fetching equipment. Choice D is incorrect as validating the client's advanced directive is not the priority in this emergency situation.
The nurse is providing teaching to a client with gastroesophageal reflux disease (GERD). Which instruction should the nurse include?
- A. Eat large meals to decrease acid production
- B. Avoid lying down immediately after eating
- C. Limit fluid intake with meals
- D. Drink carbonated beverages to aid digestion
Correct Answer: B
Rationale: The correct instruction for a client with GERD is to avoid lying down immediately after eating. This helps prevent stomach acid from flowing back into the esophagus, which can worsen symptoms. Eating large meals can actually increase acid production and exacerbate GERD. Limiting fluid intake with meals may be beneficial for some individuals, but it is not a key instruction for managing GERD. Drinking carbonated beverages can trigger reflux symptoms and should be avoided by individuals with GERD.