Nokea
A client with partial-thickness burns to the lower extremities is scheduled for whirlpool therapy to debride the burned area. Which intervention should the nurse implement before transporting the client to the physical therapy department?
- A. Apply a sterile dressing to the wound.
- B. Administer an analgesic.
- C. Encourage the client to drink fluids.
- D. Ensure the client's nutritional needs are met.
Correct Answer: B
Rationale: Administering an analgesic before whirlpool therapy is the priority intervention in this scenario. Whirlpool therapy for debridement can be painful for the client with partial-thickness burns. Administering an analgesic before the procedure helps manage pain during the debridement process, ensuring the client's comfort. Applying a sterile dressing (Choice A) may be necessary after the whirlpool therapy but is not the immediate pre-transport intervention. Encouraging the client to drink fluids (Choice C) and ensuring nutritional needs are met (Choice D) are important aspects of care but are not specifically related to preparing the client for whirlpool therapy.
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A client with chronic kidney disease is receiving epoetin alfa. Which laboratory value should the nurse monitor to determine the effectiveness of the treatment?
- A. Blood urea nitrogen (BUN)
- B. Serum creatinine
- C. Hemoglobin and hematocrit
- D. Serum potassium
Correct Answer: C
Rationale: The correct answer is C: Hemoglobin and hematocrit. Epoetin alfa is a medication that stimulates red blood cell production, so monitoring hemoglobin and hematocrit levels is essential to assess its effectiveness. These values reflect the oxygen-carrying capacity of the blood and can indicate if the treatment is improving anemia related to chronic kidney disease. Choices A, B, and D are incorrect. Blood urea nitrogen (BUN) and serum creatinine are indicators of kidney function, while serum potassium levels are monitored due to electrolyte imbalances commonly seen in kidney disease, but they do not directly reflect the effectiveness of epoetin alfa.
A client is receiving a continuous infusion of normal saline at 125 ml/hour post abdominal surgery. The client is drowsy and complaining of constant abdominal pain and a headache. Urine output is 800 ml over the past 24h with a central venous pressure of 15 mmHg. The nurse notes respiratory crackle and bounding central pulses. Vital signs: temperature 101.2°F, Heart rate 96 beats/min, Respirations 24 breaths/min, and Blood pressure 160/90 mmHg. Which interventions should the nurse implement first?
- A. Review the last administration of IV pain medication.
- B. Administer a PRN dose of acetaminophen.
- C. Decrease IV fluids to keep the vein open (KVO) rate.
- D. Calculate total intake and output.
Correct Answer: C
Rationale: The correct answer is to decrease IV fluids to the keep vein open (KVO) rate. The client is showing signs of fluid volume excess, such as drowsiness, headache, elevated CVP, crackles, bounding pulses, and increased blood pressure. Decreasing the IV fluids will help prevent further fluid overload. Reviewing the last administration of IV pain medication (Choice A) may be necessary but addressing the fluid balance issue is the priority. Administering a PRN dose of acetaminophen (Choice B) may help with the headache but does not address the underlying fluid overload. Calculating total intake and output (Choice D) is important but does not directly address the immediate issue of fluid overload and its associated symptoms.
A male client tells the nurse that he is experiencing burning on urination, and assessment reveals that he had sexual intercourse four days ago with a woman he casually met. Which action should the nurse implement?
- A. Observe the perineal area for a chancroid-like lesion.
- B. Obtain a specimen of urethral drainage for culture.
- C. Assess for perineal itching, erythema, and excoriation.
- D. Identify all sexual partners in the last four days.
Correct Answer: B
Rationale: In this scenario, the most appropriate action for the nurse to take is to obtain a specimen of urethral drainage for culture. This procedure can help diagnose the cause of burning on urination, which could be indicative of a sexually transmitted infection. Option A, observing for a chancroid-like lesion, may not be the most immediate or relevant action in this case. Option C, assessing for perineal itching, erythema, and excoriation, is important but obtaining a culture specimen would provide more specific diagnostic information. Option D, identifying all sexual partners, is relevant for contact tracing but obtaining a culture specimen is the priority to determine the current infection status.
A client who has a history of unstable angina is admitted to the emergency department with chest pain.
- A. Chest pain relieved by rest.
- B. Chest pain unrelieved after taking 3 sequential nitroglycerin tablets.
- C. Chest pain occurring only with exertion.
- D. Chest pain lasting less than 5 minutes.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with hyperkalemia is being treated in the emergency department. Which medication should the nurse prepare to administer?
- A. Potassium chloride
- B. Calcium gluconate
- C. Magnesium sulfate
- D. Sodium bicarbonate
Correct Answer: B
Rationale: The correct answer is B, Calcium gluconate. In hyperkalemia, where potassium levels are elevated, calcium gluconate is administered to stabilize the myocardial cell membrane and protect the heart from potential arrhythmias. Potassium chloride (choice A) would worsen the condition by further increasing potassium levels. Magnesium sulfate (choice C) is not the primary treatment for hyperkalemia. Sodium bicarbonate (choice D) is used in metabolic acidosis, not specifically for hyperkalemia.