Nokea
A client with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia has been receiving IV vancomycin for the last 3 days. Which blood test trend is most important for the nurse to review when preparing to administer this medication?
- A. Blood cultures
- B. Creatinine levels
- C. Magnesium levels
- D. White blood cell (WBC) count
Correct Answer: B
Rationale: Vancomycin can cause nephrotoxicity, so monitoring creatinine levels is critical to assess kidney function.
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A client with a fracture of the radius had a plaster cast applied 2 days ago. The client complains of constant pain and swelling of the fingers. The first action of the nurse should be
- A. elevate the arm no higher than heart level
- B. remove the cast
- C. assess capillary refill of the exposed hand and fingers
- D. apply a warm soak to the hand
Correct Answer: C
Rationale: A deterioration in neurovascular status indicates the development of compartment syndrome (elevated tissue pressure within a confined area) which requires immediate pressure-reducing interventions.
The nurse is caring for a client who is having a thoracentesis. Following the procedure, the nurse monitors for complications. The initial post-procedure monitoring plan should include what? Select all that apply.
- A. Level of alertness
- B. Lung sounds
- C. Oxygen saturation
- D. Respiratory pattern
- E. Temperature
- F. Urine output
Correct Answer: A,B,C,D
Rationale: Monitoring alertness, lung sounds, oxygen saturation, and respiratory pattern detects complications like pneumothorax or respiratory distress.
Which statement by the client with chronic obstructive lung disease indicates an understanding of the major reason for the use of occasional pursed-lip breathing
- A. This position of my lips helps to keep my airway open.
- B. I can expel more when I pucker up my lips to breathe out.
- C. My mouth doesn't get as dry when I breathe with pursed lips.
- D. With prolonging breathing out with pursed lips the little areas in my lungs don't collapse.
Correct Answer: D
Rationale: Clients with chronic obstructive pulmonary disease have difficulty exhaling fully as a result of weak alveolar walls. Alveolar collapse can be avoided with the use of pursed-lip breathing.
The nurse is talking about diaper changes with a client who is 48 hours postpartum. The client states, 'I cannot change my baby's diaper as well as you can. Will you change it for me?' Which of the following responses would be appropriate for the nurse to make?
- A. Changing your baby's diaper now is important for the bonding process.
- B. I will stay at your bedside and watch while you change your baby's diaper.
- C. It is more important for you to take care of yourself now, so I will change your baby's diaper.
- D. It is time that you change your baby's diaper because you will have to do it by yourself after discharge.
Correct Answer: B
Rationale: Supporting the client while they change the diaper builds confidence and promotes independence.
The nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? Select all that apply.
- A. Prepare to suction the client.
- B. Turn the client to a side-lying position.
- C. Restrain the client's upper extremities.
- D. Request assistance from other staff members.
- E. Use a tongue blade to depress the client's tongue.
Correct Answer: A,B,D
Rationale: Suctioning, side-lying position, and assistance protect the client. Restraining or using a tongue blade can cause injury.