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A client with liver cirrhosis is admitted with ascites and jaundice. Which assessment finding is most concerning?
- A. Serum albumin of 3.0 g/dL
- B. Bilirubin of 3.0 mg/dL
- C. Ammonia level of 80 mcg/dL
- D. Prothrombin time of 18 seconds
Correct Answer: C
Rationale: An ammonia level of 80 mcg/dL is elevated and concerning in a client with liver cirrhosis, as it may indicate hepatic encephalopathy. Elevated ammonia levels can lead to cognitive impairment, altered mental status, and even coma. Serum albumin, bilirubin, and prothrombin time are also important markers in liver cirrhosis but are not as directly associated with the risk of hepatic encephalopathy as elevated ammonia levels.
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The nurse is caring for a client with a history of myocardial infarction who is complaining of chest pain. Which intervention should the nurse implement first?
- A. Administer oxygen therapy as prescribed.
- B. Administer nitroglycerin sublingually as prescribed.
- C. Obtain an electrocardiogram (ECG).
- D. Assess the client's level of consciousness.
Correct Answer: C
Rationale: Obtaining an electrocardiogram (ECG) is the first priority in assessing for ischemia or infarction in a client with chest pain and a history of myocardial infarction. This diagnostic test provides crucial information about the heart's electrical activity and helps in identifying any acute cardiac changes. Administering oxygen therapy and nitroglycerin can be important interventions, but obtaining an ECG takes precedence as it directly assesses the client's cardiac status. Assessing the client's level of consciousness is also essential, but in this scenario, assessing for cardiac indications through an ECG is the initial step.
A male client with ulcerative colitis received a prescription for a corticosteroid last month, but because of the side effects, he stopped taking the medication 6 days ago. Which finding warrants immediate intervention by the nurse?
- A. Anxiety and restlessness
- B. Increased bowel movements
- C. Abdominal cramping
- D. Fever and chills
Correct Answer: A
Rationale: The correct answer is A: Anxiety and restlessness. Abruptly stopping corticosteroids can cause adrenal insufficiency, leading to symptoms such as anxiety and restlessness. These symptoms indicate a potential serious complication that requires immediate intervention. Increased bowel movements and abdominal cramping are common side effects of ulcerative colitis and may not warrant immediate intervention. Fever and chills are not typically associated with adrenal insufficiency caused by corticosteroid withdrawal.
An 11-year-old client is admitted to the mental health unit after trying to run away from home and threatening self-harm. The nurse establishes a goal to promote effective coping and plans to ask the client to verbalize three ways to deal with stress. Which activity is best to establish rapport and accomplish this therapeutic goal?
- A. Play a board game with the client and begin talking about stressors
- B. Conduct a formal therapy session
- C. Ask the client to write down their feelings
- D. Have a group discussion about stress management
Correct Answer: A
Rationale: Playing a board game with the client and initiating a conversation about stressors is the best choice to establish rapport and achieve the therapeutic goal of helping the client verbalize ways to cope with stress. Board games provide a relaxed and non-threatening environment, allowing the client to feel more comfortable and open up about their stressors. Choice B, conducting a formal therapy session, might be too structured and intimidating for the client, hindering open communication. Choice C, asking the client to write down their feelings, lacks the interactive and engaging aspect that a board game provides. Choice D, having a group discussion about stress management, may not be as effective initially as one-on-one interaction to build trust and rapport with the client.
The nurse needs to add a medication to a liter of 5% Dextrose in Water (D5W) that is already infusing into a client. At what location should the nurse inject the medication?
- A. Medication port
- B. IV drip chamber
- C. Y-site connector
- D. At the hub of the IV catheter
Correct Answer: A
Rationale: The correct answer is the medication port. When adding medication to an already infusing IV solution, it should be done through the medication port to ensure direct delivery into the bloodstream without interrupting the primary IV line. Injecting the medication into the IV drip chamber, Y-site connector, or at the hub of the IV catheter can lead to dilution, inaccurate dosing, or potential blockages in the IV line, which can compromise the effectiveness of the medication and patient safety.
A client with type 1 diabetes is admitted with hypoglycemia. Which intervention should the nurse implement first?
- A. Administer 50% dextrose IV push
- B. Administer 15 grams of oral glucose
- C. Recheck the blood glucose level in 15 minutes
- D. Administer a glucagon injection
Correct Answer: A
Rationale: Administering 50% dextrose IV push is the first priority in treating hypoglycemia to rapidly increase blood glucose levels. This choice is correct because in severe cases of hypoglycemia, when a client is admitted and unconscious or unable to swallow, intravenous administration of dextrose is crucial to quickly raise blood glucose levels. Option B, administering 15 grams of oral glucose, would be suitable for conscious clients with mild hypoglycemia who can swallow safely. Option C, rechecking blood glucose levels, should follow after immediate intervention to assess the response. Option D, administering a glucagon injection, is more suitable for cases where dextrose is not readily available or when the client does not respond to dextrose administration.