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A nurse in an outpatient surgical center is admitting a client for a laparoscopic procedure. The client has a prescription for preoperative diazepam. Prior to administering the medication, which of the following actions is the nurse's priority?
- A. Teaching the client about the purpose of the medication
- B. Giving the medication at the administration time the provider prescribed
- C. Identifying the client's medication allergies
- D. Documenting the client's anxiety level
Correct Answer: C
Rationale: The correct answer is C: Identifying the client's medication allergies. This is the priority action before administering any medication to prevent allergic reactions or adverse effects. Teaching the client about the medication's purpose is important for client understanding but not as critical as ensuring the absence of allergies. While giving medication at the prescribed time is crucial, verifying allergies takes precedence to ensure patient safety. Documenting the client's anxiety level is relevant for holistic care but is not the priority compared to ensuring safe medication administration.
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The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the following assessments is MOST critical for the nurse to include in the plan of care?
- A. Hourly urine output
- B. White blood cell count
- C. Blood glucose every 4 hours
- D. Temperature every 2 hours
Correct Answer: A
Rationale: Monitoring hourly urine output is crucial after successful resuscitation from a pulseless dysrhythmia to assess kidney function and perfusion. The kidneys are particularly vulnerable to injury following cardiac events due to decreased perfusion during the event. Evaluating urine output hourly allows for early detection of renal impairment or inadequate organ perfusion. Option B, monitoring white blood cell count, is not a priority in this situation as it does not directly relate to immediate post-resuscitation care. Option C, checking blood glucose every 4 hours, is important but not as critical as assessing kidney function and perfusion. Option D, measuring temperature every 2 hours, is relevant for monitoring signs of infection or inflammatory response but is not as crucial as assessing kidney function in this scenario.
In an emergency department, a nurse is assessing a client who reports right lower quadrant pain, nausea, and vomiting for the past 48 hours. Which of the following actions should the nurse take first?
- A. Auscultate bowel sounds.
- B. Administer an antiemetic.
- C. Offer pain medication.
- D. Palpate the abdomen.
Correct Answer: A
Rationale: The correct action the nurse should take first is to auscultate bowel sounds. This step is crucial to assess bowel activity before proceeding with palpation or administering medications. Assessing bowel sounds can provide valuable information about bowel motility and potential obstructions. Administering an antiemetic or offering pain medication may be necessary but should come after assessing bowel sounds to ensure appropriate treatment. Palpating the abdomen should be avoided initially to prevent potential discomfort or complications, especially if there is suspected abdominal pathology.
After abdominal surgery, a client has not urinated since the urinary catheter was removed 8 hours ago. What action should the LPN take first?
- A. Perform a bladder scan to assess for urinary retention.
- B. Encourage the client to drink fluids.
- C. Insert a straight catheter to drain the bladder.
- D. Administer a diuretic as prescribed.
Correct Answer: A
Rationale: Performing a bladder scan is the initial step to assess for urinary retention in a postoperative client. This non-invasive technique helps determine the volume of urine in the bladder, guiding further interventions. Encouraging the client to drink fluids (Choice B) may be beneficial but is not the priority when assessing for urinary retention. Inserting a straight catheter (Choice C) should not be the initial action without first assessing for retention. Administering a diuretic (Choice D) should not be done without confirming the need through assessment.
The nurse is caring for a client with hyperthyroidism. Which finding should the nurse expect to observe in this client?
- A. Weight loss
- B. Cold intolerance
- C. Bradycardia
- D. Dry skin
Correct Answer: A
Rationale: Weight loss is a common finding in clients with hyperthyroidism due to increased metabolic activity. Hyperthyroidism leads to an overactive thyroid gland, which results in an increased metabolic rate and often leads to weight loss despite a normal or increased appetite. Cold intolerance (Choice B) is more commonly associated with hypothyroidism, where the body's processes slow down. Bradycardia (Choice C) is a slow heart rate, which is not typically seen in hyperthyroidism; rather, tachycardia or an increased heart rate is more common. Dry skin (Choice D) is also not a typical finding in hyperthyroidism, as the skin is more likely to be warm and moist due to increased metabolic activity.
A client requires gastric decompression, and a nurse is inserting an NG tube. Which action should the nurse take to verify proper placement of the tube?
- A. Assess the client for a gag reflex
- B. Measure the pH of the gastric aspirate
- C. Place the end of the NG tube in water to observe for bubbling
- D. Auscultate 2.5 cm (1 in) above the umbilicus while injecting 15 mL of sterile water
Correct Answer: B
Rationale: Measuring the pH of the gastric aspirate is the most reliable method to confirm proper placement of an NG tube. Gastric fluid has an acidic pH, typically ranging from 1 to 5. Assessing the client for a gag reflex (choice A) is important for airway protection but does not confirm tube placement. Placing the NG tube in water to observe for bubbling (choice C) is incorrect and not a reliable method for verifying placement. Auscultating 2.5 cm above the umbilicus while injecting sterile water (choice D) is an outdated method and is not recommended for verifying NG tube placement.