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A confused, older client with Alzheimer's disease becomes incontinent of urine when attempting to find the bathroom. Which action should the nurse implement?
- A. Assist the client to a bedside commode every two hours
- B. Insert an indwelling catheter
- C. Use adult diapers to manage incontinence
- D. Restrict fluids in the evening
Correct Answer: A
Rationale: The correct action for the nurse to implement is to assist the client to a bedside commode every two hours. This approach, known as scheduled toileting, is essential in managing incontinence in clients with cognitive impairments like Alzheimer's disease. By providing regular assistance to the client to use the commode, the nurse can help maintain continence and reduce accidents. Inserting an indwelling catheter (Choice B) should be avoided if possible to prevent the risk of urinary tract infections. Using adult diapers (Choice C) should be considered a last resort and not the initial intervention. Restricting fluids in the evening (Choice D) is not appropriate as it may lead to dehydration and other complications.
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A client with rheumatoid arthritis is prescribed methotrexate. Which laboratory value should the nurse monitor closely?
- A. White blood cell count of 10,000/mm³
- B. Hemoglobin of 12 g/dL
- C. Liver function tests
- D. Platelet count of 150,000/mm³
Correct Answer: C
Rationale: The correct answer is C: Liver function tests. Methotrexate can cause hepatotoxicity, making it essential to closely monitor liver function tests in clients receiving this medication. Monitoring white blood cell count, hemoglobin, or platelet count is not specifically required for methotrexate therapy and would not provide relevant information regarding potential adverse effects of the medication.
An adult female client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. The nurse notices the client has more energy and is giving her belongings away. Which intervention is best for the nurse to implement?
- A. Support the client by praising her progress.
- B. Ask the client if she has had any recent thoughts of harming herself.
- C. Reassure the client about the effectiveness of antidepressant drugs.
- D. Advise the client to keep her belongings for discharge.
Correct Answer: B
Rationale: The correct intervention is to ask the client if she has had any recent thoughts of harming herself because increased energy and giving away belongings can be signs of suicidal ideation. Choice A is incorrect as it does not address the potential risk of self-harm. Choice C is incorrect because reassurance about medication effectiveness may not be appropriate in this situation. Choice D is incorrect as it dismisses the client's current behavior without addressing the underlying concern of potential self-harm.
The client with end-stage renal disease (ESRD) is scheduled for hemodialysis. Which laboratory value is most concerning?
- A. Serum potassium of 6.0 mEq/L
- B. Serum creatinine of 2.5 mg/dL
- C. Serum calcium of 8.0 mg/dL
- D. Hemoglobin of 10 g/dL
Correct Answer: A
Rationale: A serum potassium level of 6.0 mEq/L is most concerning in a client with ESRD scheduled for hemodialysis as it indicates hyperkalemia, which can lead to serious cardiac complications such as arrhythmias and cardiac arrest. Immediate intervention is required to lower potassium levels.
Choice B, serum creatinine of 2.5 mg/dL, is elevated but expected in ESRD due to impaired kidney function. Choice C, serum calcium of 8.0 mg/dL, is within the normal range and not typically a priority in this situation. Choice D, hemoglobin of 10 g/dL, is slightly low but not an immediate concern for a client scheduled for hemodialysis unless significantly lower and causing severe symptoms.
During the initial visit to a client with MS who is bed-bound and lifted by a hoist, which intervention is most important for the nurse to implement?
- A. Determine how the client is cared for when the caregiver is not present.
- B. Develop a client needs assessment and review it with the caregiver.
- C. Evaluate the caregiver's ability to care for the client's needs.
- D. Review with the caregiver the interventions provided each day.
Correct Answer: A
Rationale: During the initial visit, the most crucial intervention for the nurse is to determine how the client is cared for when the caregiver is not present. This is essential to ensure the client's safety and well-being, especially during times when the caregiver is not available. Option B is not the most important as it focuses on assessment rather than immediate safety concerns. Option C, while important, is secondary to ensuring continuous care. Option D is less critical during the initial visit compared to ensuring care continuity in the caregiver's absence.
The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine, and the UAP is placing soft pillows along the side rails. What action should the nurse take?
- A. Ensure that the UAP has positioned the pillows effectively to protect the client.
- B. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows.
- C. Assume responsibility for placing the pillows while the UAP completes another task.
- D. Ask the UAP to use some of the pillows to prop the client in a side-lying position.
Correct Answer: B
Rationale: The nurse should instruct the UAP to pad the side rails with soft blankets instead of pillows. Placing pillows along the side rails could lead to suffocation during a seizure and would need to be removed promptly. Instructing the UAP to use soft blankets is safer as they can help prevent injury without posing a risk of suffocation. Ensuring effective placement of the pillows (Choice A) is not appropriate as pillows should not be used in this situation. Assuming responsibility for placing the pillows (Choice C) or propping the client in a side-lying position with pillows (Choice D) are both unsafe actions and could potentially harm the client.