Nokea
A male client with hypertension, who received new antihypertensive prescriptions at his last visit, returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106, and he admits that he has not been taking the prescribed medication because the drugs make him 'feel bad.' In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?
- A. Feed the client a snack
- B. Empty the urinary drainage bag
- C. Offer the client oral fluids
- D. Stroke secondary to hemorrhage
Correct Answer: D
Rationale: Elevated blood pressure, if left uncontrolled, significantly increases the risk of stroke secondary to hemorrhage and other cardiovascular events. This condition can lead to serious complications due to the increased pressure on the blood vessels in the brain. Choices A, B, and C are unrelated to the potential pathophysiological consequences of uncontrolled hypertension and are not the primary concern in this scenario.
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What action should the nurse take after a client produces the first of a series of sputum samples for cytology?
- A. Ensure the client remains NPO until all samples are collected
- B. Transport the sputum container to the laboratory in a biohazard bag
- C. Discard the initial sample and document the time it was obtained
- D. Document the time the client last ate or drank on the laboratory slip
Correct Answer: B
Rationale: The correct action for the nurse to take after a client produces the first of a series of sputum samples for cytology is to transport the sputum container to the laboratory in a biohazard bag. This is important to ensure proper handling and prevent contamination of the sample. Choice A is incorrect because there is no need to keep the client NPO until all samples are collected. Choice C is incorrect as the initial sample should not be discarded but rather transported to the laboratory. Choice D is also incorrect as documenting the time the client last ate or drank is not directly relevant to the immediate action needed for the sputum sample.
A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take?
- A. Call the radiology department
- B. Reinsert the implant into the vagina
- C. Apply double gloves to retrieve the implant for disposal
- D. Place the implant in a lead container using long-handled forceps
Correct Answer: D
Rationale: The correct action for the nurse to take when finding a radiation implant in the bed is to place the implant in a lead container using long-handled forceps. This action is crucial to minimize radiation exposure to both the patient and healthcare providers and ensure the safe disposal of the radioactive material. Calling the radiology department (choice A) may lead to unnecessary delays in addressing the immediate safety concern. Reinserting the implant into the vagina (choice B) is contraindicated and can cause harm. Applying double gloves to retrieve the implant for disposal (choice C) is not adequate for ensuring proper containment and handling of the radioactive implant, which requires specialized equipment like a lead container and long-handled forceps.
A high school football player comes to the clinic complaining of severe acne. The mother reports recent behavior changes, including irritability and suspiciousness of friends. The nurse's assessment reveals an elevated blood pressure. Which intervention should the nurse implement first?
- A. Encourage the client to see a dermatologist
- B. Refer the adolescent to a substance abuse program
- C. Suggest a low-salt, low-fat, and caffeine-free diet
- D. Inquire about a possible use of anabolic steroids
Correct Answer: D
Rationale: In this scenario, the high school football player presenting with severe acne, behavior changes, elevated blood pressure, and suspicion of friends suggests the possible use of anabolic steroids. Anabolic steroid use can lead to such symptoms. Therefore, the nurse should first inquire about the possible use of anabolic steroids to address the root cause of the presenting issues. Encouraging the client to see a dermatologist (Choice A) may be necessary but addressing the underlying cause is crucial first. Referring the adolescent to a substance abuse program (Choice B) is premature without confirming steroid use. Suggesting a low-salt, low-fat, and caffeine-free diet (Choice C) is not the priority in this situation where a serious issue like anabolic steroid use needs immediate attention.
While caring for a client with bilateral chest tubes, the bubbling in the water-seal chamber of the right chest tube stops. What action is most important for the nurse to take?
- A. Check the chest tube connections to the water-seal container
- B. Replace the water-seal collection container
- C. Increase the amount of wall suction connected to the right chest tube
- D. Milk the tubing connected to the right chest tube
Correct Answer: A
Rationale: The most important action for the nurse to take when the bubbling in the water-seal chamber of the right chest tube stops is to check the chest tube connections to the water-seal container. This is crucial to ensure there are no disconnections or leaks affecting the bubbling. Replacing the water-seal collection container (choice B) is not necessary unless there is a malfunction; increasing suction (choice C) without assessing the connections can be harmful, and 'milking' the tubing (choice D) is an inappropriate action that can cause damage to the system.
The nurse is teaching a male adolescent recently diagnosed with type 1 diabetes mellitus (DM) about self-injecting insulin. Which approach is best for the nurse to use to evaluate the effectiveness of the teaching?
- A. Observe him demonstrating the self-injection technique to another diabetic adolescent.
- B. Ask the adolescent to describe his comfort level with injecting himself with insulin.
- C. Review his glycosylated hemoglobin level 3 months after the teaching session.
- D. Have the adolescent list the steps for safe insulin administration.
Correct Answer: C
Rationale: Reviewing the glycosylated hemoglobin level after a few months is the best approach to evaluate the effectiveness of teaching self-injection. This measurement provides an objective indicator of the adolescent's glucose control over time, reflecting the impact of insulin self-administration education. Choices A, B, and D do not directly assess the long-term impact of the teaching on the adolescent's diabetes management.