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A client with rheumatoid arthritis reports a new onset of increasing fatigue. What intervention should the nurse implement first?
- A. Assist the client in conserving energy during daily activities
- B. Explain to the client that this could be a side effect of the medication
- C. Assess the client for pallor
- D. Encourage the client to maintain a balanced diet and hydration
Correct Answer: C
Rationale: The correct first intervention for a client with rheumatoid arthritis reporting increasing fatigue is to assess the client for pallor. Fatigue can be a sign of anemia or other complications; assessing for pallor can help determine if anemia is the cause. Option A is incorrect as it does not address the underlying cause of fatigue. Option B assumes the cause without further assessment. Option D is important for overall health but assessing for pallor takes precedence to identify immediate issues related to fatigue.
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A client is admitted with severe dehydration. What is the most important assessment finding for the nurse to monitor?
- A. Changes in mental status
- B. Urine output and color
- C. Blood pressure and heart rate
- D. Skin turgor
Correct Answer: A
Rationale: Changes in mental status are crucial to monitor in a client with severe dehydration. Altered mental status, such as confusion or lethargy, can indicate severe dehydration and potential complications like electrolyte imbalances affecting the brain. Monitoring urine output and color (choice B) is essential but may not provide immediate signs of severe dehydration. While monitoring blood pressure and heart rate (choice C) is important, changes in mental status take precedence as they can indicate more critical conditions. Skin turgor (choice D) is a valuable assessment for dehydration, but changes in mental status take priority due to their direct correlation with severe dehydration.
Following the evacuation of a subdural hematoma, an older adult develops an infection. The client is transferred to the neuro intensive care unit with a temperature of 101.8 F (39.3 C) axillary, pulse of 180 beats/minute, and a blood pressure of 90/60 mmHg. What is the priority intervention to include in this client's plan of care?
- A. Confusion
- B. Check neuro vital signs every 4 hours.
- C. Maintain intravenous access.
- D. Keep the suture line clean and dry.
Correct Answer: C
Rationale: The priority intervention for the client in this scenario is to maintain intravenous (IV) access. Given the client's condition with infection, elevated temperature, tachycardia, and hypotension, it is crucial to ensure IV access for administering antibiotics, fluids, and other medications promptly. This can help manage the infection, stabilize hemodynamics, and support the client's hydration and medication needs. Checking neuro vital signs, although important, is secondary to addressing the immediate need for IV access. Keeping the suture line clean and dry is important for wound care but not the priority when dealing with a systemic infection and hemodynamic instability.
Several clients on a busy antepartum unit are scheduled for procedures that require informed consent. Which situation should the nurse explore further before witnessing the client's signature on the consent form?
- A. The client was medicated for pain with a narcotic analgesic IM 6 hours ago
- B. A 15-year-old primigravida who has been self-supporting for the past 6 months
- C. The obstetrician explained a procedure that a neurologist will perform
- D. The client is illiterate but verbalizes understanding and consent for the procedure
Correct Answer: D
Rationale: The correct answer is D because an illiterate client may require additional support to ensure they fully comprehend the information provided in the informed consent process. It is crucial to confirm that the client truly understands the nature of the procedure, its risks, and benefits. While it is important to assess pain control (choice A), a client's previous medication administration does not directly impact their ability to understand the consent process. Choice B, a 15-year-old primigravida who has been self-supporting, may legally provide informed consent depending on the jurisdiction and circumstances, so this situation may not require further exploration. Choice C, explaining a procedure by a different specialist, does not necessarily require additional exploration before witnessing the client's consent.
The nurse is preparing to administer an IM injection to a 6-month-old child. Which injection site is best for the nurse to use?
- A. Vastus lateralis
- B. Deltoid
- C. Ventrogluteal
- D. Dorsogluteal
Correct Answer: A
Rationale: The vastus lateralis is the preferred site for IM injections in infants due to their limited muscle mass and safety. Infants do not have well-developed muscle mass, making the vastus lateralis the best option for IM injections. The deltoid muscle is typically used for older children and adults. Ventrogluteal and dorsogluteal sites are not recommended for infants due to safety concerns, including the risk of damaging the sciatic nerve. Therefore, the correct choice is the vastus lateralis for IM injections in infants.
The client demonstrates an understanding of sliding scale insulin administration instructions by performing the procedure in which order?
- A. Obtain blood glucose level
- B. Verify the insulin prescription
- C. Draw insulin into insulin syringe
- D. Cleanse the selected site
Correct Answer: A
Rationale: The correct order for the client to perform the procedure is to first obtain the blood glucose level. This step is crucial as it helps determine the appropriate dose of insulin based on the sliding scale. Verifying the insulin prescription, drawing insulin into the syringe, and cleansing the selected site are important steps in the process but should follow after obtaining the blood glucose level. Therefore, options B, C, and D are incorrect in terms of the initial steps required for sliding scale insulin administration.