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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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At 42-weeks gestation, a client refuses induction and desires a natural delivery. What is the most important action for the nurse to take?
- A. Discuss alternative ways to support her birth plan.
- B. Explain the indications for induction in post-term pregnancy.
- C. Discuss the differences between labor with oxytocin and natural labor.
- D. Ask the healthcare provider to discuss the issue with the client.
Correct Answer: A
Rationale: The correct answer is to discuss alternative ways to support her birth plan. It is crucial to respect the client's autonomy and desires while ensuring their safety and well-being. Choice B is incorrect because while educating the client about the indications for induction is important, it is not the most immediate action to take in this scenario. Choice C is incorrect as it focuses on comparing labor types rather than supporting the client's birth plan. Choice D is incorrect as the nurse should first engage with the client directly before involving the healthcare provider.
A client with end-stage pulmonary disease requests 'no heroic measures' if she stops breathing. What should the nurse do next?
- A. Document the client's request in the medical record.
- B. Ask the client to discuss a DNR order with her healthcare provider.
- C. Consult the ethics committee for guidance.
- D. Discharge the client with no further discussion.
Correct Answer: B
Rationale: The correct next step for the nurse is to ask the client to discuss a 'do not resuscitate' (DNR) order with her healthcare provider. While the client's wishes should be respected, it is essential to ensure proper documentation and legal protection by involving the healthcare provider in this decision-making process. Documenting the request in the medical record (Choice A) is important but should follow the discussion with the healthcare provider. Consulting the ethics committee (Choice C) may not be necessary at this stage and could delay the necessary actions. Discharging the client (Choice D) without further discussion is not appropriate and disregards the importance of addressing the client's wishes in a respectful and professional manner.
A client presses the call bell and requests pain medication for a severe headache. To assess the quality of the client's pain, which approach should the nurse use?
- A. Use the Wong-Baker Faces pain rating scale
- B. Assess vital signs to gauge pain severity
- C. Ask the client to describe the pain
- D. Offer a 1-10 pain scale
Correct Answer: C
Rationale: Asking the client to describe the pain is the most appropriate approach to assess the quality of pain. It provides valuable qualitative information that aids in understanding the nature, cause, and potential management strategies for the headache. While pain rating scales like the Wong-Baker Faces scale and using vital signs can help quantify pain severity, they do not offer specific descriptive details that can give insights into the type and characteristics of the pain experienced by the client.
A client presents with severe dehydration due to prolonged vomiting. What is the nurse's priority intervention?
- A. Encourage the client to drink clear fluids.
- B. Assess the client's skin turgor and mucous membranes.
- C. Monitor the client's vital signs frequently.
- D. Administer an antiemetic as prescribed.
Correct Answer: B
Rationale: The correct answer is to assess the client's skin turgor and mucous membranes. When a client presents with severe dehydration, assessing skin turgor (elasticity of the skin) and mucous membranes (such as checking for dryness in the mouth) is crucial in determining the extent of dehydration. Encouraging the client to drink clear fluids (Choice A) may be important but assessing dehydration severity takes precedence. Monitoring vital signs (Choice C) is essential but assessing dehydration status comes first. Administering an antiemetic (Choice D) addresses vomiting but does not directly assess dehydration.
An adolescent client with meningococcal meningitis is receiving a continuous IV infusion of penicillin G. How many mL/hour should the nurse program the infusion pump to deliver?
- A. 83
- B. 85
- C. 87
- D. 90
Correct Answer: A
Rationale: The correct answer is A: 83. The pharmacy provided the infusion at 10 million units per liter, which requires a rate of 83 mL/hour. To calculate this, multiply the dosage by the volume of the IV solution and divide by the concentration of the IV solution in million units: 10 million units per liter x 8.3 L = 83 mL/hour. Choices B, C, and D are incorrect as they do not align with the calculation based on the given information.