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A client with pheochromocytoma is admitted to the hospital. Which intervention has the highest priority?
- A. Monitor blood pressure frequently
- B. Start intravenous fluids at a fast rate
- C. Administer pain medication to reduce discomfort
- D. Give antihypertensive medications as prescribed
Correct Answer: B
Rationale: The correct answer is B: Start intravenous fluids at a fast rate. In a client with pheochromocytoma, the highest priority intervention is to ensure adequate intravascular volume before initiating any other treatment. This helps prevent a sudden drop in blood pressure that can occur due to the release of catecholamines during tumor manipulation. While monitoring blood pressure frequently is essential, ensuring adequate intravascular volume takes precedence. Administering pain medication and antihypertensive medications are important but are not the highest priority in the initial management of pheochromocytoma.
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A client with multiple sclerosis is admitted with an acute exacerbation. What is the nurse's priority action?
- A. Monitor the client's vital signs every hour.
- B. Assess for changes in the client's muscle strength.
- C. Administer prescribed corticosteroids to reduce inflammation.
- D. Educate the client on managing fatigue and preventing relapses.
Correct Answer: C
Rationale: The correct answer is C. Administering prescribed corticosteroids to reduce inflammation is the priority action when a client with multiple sclerosis is admitted with an acute exacerbation. Corticosteroids help manage symptoms during exacerbations and reduce inflammation. Monitoring vital signs and assessing muscle strength are important aspects of care but not the priority during an acute exacerbation. Educating the client on managing fatigue and preventing relapses is essential but can be addressed after the acute exacerbation has been managed.
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.
Which client is at greatest risk for developing delirium?
- A. An adult client who cannot sleep due to pain.
- B. An older client who attempted suicide 1 month ago.
- C. A young adult taking antipsychotic medications twice daily.
- D. A middle-aged woman using supplemental oxygen.
Correct Answer: B
Rationale: The correct answer is B. Older adults who have attempted suicide are at higher risk for developing delirium, especially in the context of underlying mental health conditions. Choice A is incorrect as sleep disturbances due to pain may lead to discomfort but not necessarily delirium. Choice C is incorrect as taking antipsychotic medications, if managed well, does not inherently increase the risk of delirium. Choice D is incorrect as using supplemental oxygen alone does not significantly increase the risk of developing delirium.
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 nurse receives a report on a client who is four hours post-total abdominal hysterectomy. The previous nurse reported that it was necessary to change the client's perineal pad hourly and that it is again saturated. The previous nurse also reports that the client's urinary output has decreased. Which action should the nurse implement first?
- A. Measure urinary output
- B. Assess for weakness or dizziness
- C. Increase IV fluids
- D. Check for vaginal bleeding
Correct Answer: D
Rationale: Saturation of the perineal pad after a hysterectomy suggests excessive vaginal bleeding, which must be addressed immediately. Assessing for vaginal bleeding is the priority in this situation as it can lead to hypovolemic shock. Measuring urinary output, assessing for weakness or dizziness, and increasing IV fluids are important interventions but checking for vaginal bleeding takes precedence due to the risk of hemorrhage post-hysterectomy.