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A client with type 1 diabetes is admitted to the emergency room with abdominal pain, polyuria, and confusion. What should the nurse implement first?
- A. Administer intravenous insulin.
- B. Start an intravenous fluid bolus.
- C. Obtain a blood glucose level.
- D. Administer an antiemetic.
Correct Answer: B
Rationale: In this scenario, the nurse should first start an intravenous fluid bolus. This intervention is crucial in addressing severe dehydration associated with diabetic ketoacidosis, a life-threatening complication of type 1 diabetes. Administering intravenous insulin (Choice A) is important but should follow fluid resuscitation. Obtaining a blood glucose level (Choice C) is necessary but not as urgent as addressing the dehydration. Administering an antiemetic (Choice D) is not the priority in this situation.
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A client presents to the labor and delivery unit with a report of leaking fluid that is greenish-brown vaginal discharge. Which action should the nurse take first?
- A. Notify the healthcare provider immediately
- B. Begin continuous fetal monitoring
- C. Check the amniotic fluid pH
- D. Assess maternal vital signs
Correct Answer: B
Rationale: Greenish-brown discharge likely indicates meconium in the amniotic fluid, which poses a risk to the fetus. Continuous fetal monitoring should be initiated immediately to assess for signs of fetal distress. Meconium-stained amniotic fluid can lead to meconium aspiration syndrome in the newborn, so timely monitoring is crucial. Checking the amniotic fluid pH can help confirm the presence of meconium but is not the priority over fetal monitoring. Assessing maternal vital signs is important but secondary to monitoring the fetal well-being in this urgent situation. Notifying the healthcare provider can follow once the immediate fetal assessment is underway.
A client with chronic kidney disease is prescribed a low-potassium diet. Which food should the nurse instruct the client to avoid?
- A. Carrots
- B. White bread
- C. Bananas
- D. Apples
Correct Answer: C
Rationale: The correct answer is C: Bananas. Bananas are high in potassium and should be avoided in clients who are on a low-potassium diet due to chronic kidney disease. Foods like apples and white bread are low in potassium and are safer choices. Carrots are also low in potassium and do not need to be avoided in this case.
A nurse is working with a new graduate nurse on the delegation of tasks to the unlicensed assistive personnel (UAP). Which task would the new nurse need more teaching about delegating?
- A. Taking a client's blood pressure
- B. Providing oral hygiene for a client
- C. Assessing a client's pain level
- D. Assisting a client with ambulation
Correct Answer: C
Rationale: The correct answer is C: Assessing a client's pain level. This task involves clinical judgment and interpretation, which are within the scope of a licensed nurse's practice. Delegating pain assessment to unlicensed personnel could lead to errors in pain management and inappropriate interventions. Choices A, B, and D involve tasks that can be safely delegated to unlicensed assistive personnel as they do not involve interpretation or nursing judgment. Taking a client's blood pressure, providing oral hygiene, and assisting with ambulation are all routine tasks that can be appropriately assigned to UAP under the supervision of a licensed nurse.
A client is experiencing angina at rest. Which statement indicates a good understanding of the care required?
- A. I will notify the nurse if my chest pain is not relieved in 30 minutes.
- B. I will use nitroglycerin as needed, every 5 minutes, up to 3 doses.
- C. I will avoid physical activity until the pain subsides completely.
- D. I will take nitroglycerin 30 minutes before any physical activity.
Correct Answer: B
Rationale: The correct answer is B. Using nitroglycerin as needed, every 5 minutes, up to 3 doses, is the appropriate management for angina at rest. This helps dilate blood vessels, improving blood flow to the heart. Choice A is incorrect because chest pain that persists at rest should be addressed immediately, not waiting for 30 minutes. Choice C is incorrect as avoiding physical activity is not a recommended approach during an angina episode. Choice D is incorrect because nitroglycerin should be used during chest pain episodes, not as a preventive measure before physical activity.
A client with a chest tube following a pneumothorax is complaining of increased shortness of breath. What is the nurse's first action?
- A. Check for kinks in the chest tube tubing.
- B. Assess the client's lung sounds.
- C. Elevate the head of the bed to 30 degrees.
- D. Prepare for chest tube replacement.
Correct Answer: C
Rationale: The correct first action for a client with a chest tube experiencing increased shortness of breath is to elevate the head of the bed to 30 degrees. This position promotes lung expansion, improves oxygenation, and can help relieve shortness of breath. Checking for kinks in the chest tube tubing would be important but not the first action in this situation. Assessing the client's lung sounds is also important but not the initial priority. Preparing for chest tube replacement is not indicated based solely on the client's complaint of increased shortness of breath.