Nokea
A nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse?
- A. A client with a Dopamine drip IV with vital signs monitored every 5 minutes
- B. A client with a myocardial infarction that is free from pain and dysrhythmias
- C. A client with a tracheotomy of 24 hours in some respiratory distress
- D. A client with a pacemaker inserted this morning with intermittent capture
Correct Answer: B
Rationale: In this scenario, it is more appropriate to assign a stable client, such as the one with a myocardial infarction who is free from pain and dysrhythmias, to a nurse who lacks specialized critical care experience. This client's condition is relatively stable and does not require immediate critical interventions. Choices A, C, and D involve clients with more complex and critical conditions that would be better managed by a nurse with specialized critical care training. Choice A involves a client on a Dopamine drip with frequent vital sign monitoring, Choice C has a client with a tracheotomy in respiratory distress, and Choice D describes a client with a pacemaker experiencing intermittent capture, all of which require a higher level of critical care expertise.
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A client with a history of deep vein thrombosis (DVT) is prescribed warfarin. Which laboratory value should the nurse monitor to assess the therapeutic effect of this medication?
- A. Platelet count
- B. Prothrombin time (PT)
- C. White blood cell count
- D. Hemoglobin level
Correct Answer: B
Rationale: Prothrombin time (PT) is the correct laboratory value to monitor to assess the therapeutic effect of warfarin. Warfarin works by inhibiting clotting factors, and PT measures the time it takes for blood to clot. Monitoring PT helps ensure that the medication is working effectively to prevent clot formation without causing excessive bleeding. Platelet count (Choice A) is not specific to warfarin therapy and assesses the number of platelets in the blood. White blood cell count (Choice C) and hemoglobin level (Choice D) are not directly related to monitoring the therapeutic effect of warfarin.
What are the primary pathophysiological mechanisms responsible for ascites in liver failure?
- A. Decreased liver enzymes.
- B. Increased hydrostatic pressure in portal circulation.
- C. High bilirubin levels.
- D. Fluid shifts due to decreased serum proteins.
Correct Answer: B
Rationale: The correct answer is B: Increased hydrostatic pressure in portal circulation. Ascites in liver failure is primarily caused by fluid shifts from the intravascular space to the interstitial space due to increased hydrostatic pressure in the portal circulation. Choice A is incorrect as ascites is not caused by decreased liver enzymes. Choice C is incorrect as high bilirubin levels are not the primary mechanism for ascites in liver failure. Choice D is incorrect as fluid shifts in ascites are due to decreased serum proteins, not increased serum proteins.
The nurse leading a medical-surgical unit care team assigns client care to a PN and a UAP. Which task should the nurse delegate to the UAP?
- A. Assess a client's pain level post-surgery
- B. Turn and reposition a client with a total hip replacement
- C. Administer a dose of insulin per sliding scale
- D. Change a postoperative dressing
Correct Answer: B
Rationale: Turning and repositioning a client is within the scope of practice of a UAP. This task helps prevent pressure ulcers and assists in maintaining the client's comfort and mobility. Assessing pain level post-surgery requires clinical judgment and interpretation, making it appropriate for a PN or RN. Administering medication like insulin involves critical thinking and potential adjustments based on the client's condition, which is the responsibility of a licensed nurse. Changing postoperative dressings involves wound assessment, infection control, and knowledge of aseptic techniques, tasks that fall under the purview of a PN or RN.
A client with dyspnea is being admitted to the medical unit. To best prepare for the client's arrival, the nurse should ensure that the client's bed is in which position?
- A. Trendelenburg
- B. Supine
- C. Prone
- D. Fowler's
Correct Answer: D
Rationale: Fowler's position (head elevated at 45-60 degrees) improves oxygenation by expanding the lungs, making it the best position for clients with dyspnea. Supine or prone positions restrict lung expansion, and Trendelenburg position (head down) can exacerbate breathing difficulties by increasing pressure on the lungs and diaphragm.
The nurse is providing discharge teaching to a client with gastroesophageal reflux disease (GERD). Which instruction should the nurse include in the teaching?
- A. Increase fluid intake with meals
- B. Avoid lying down for at least 30 minutes after eating
- C. Eat small, frequent meals throughout the day
- D. Consume spicy foods in moderation
Correct Answer: C
Rationale: The correct instruction for the nurse to include in the teaching for a client with GERD is to eat small, frequent meals throughout the day. This recommendation helps reduce symptoms by preventing the stomach from becoming overly full, which can increase pressure on the lower esophageal sphincter and lead to acid reflux. Choices A, B, and D are incorrect because increasing fluid intake with meals can exacerbate GERD symptoms, lying down after eating can worsen reflux, and consuming spicy foods can trigger acid reflux in individuals with GERD.