Nokea
A nurse is admitting a client who has recently developed fever, confusion, and a decreased level of consciousness. Which of the following actions should the nurse take first after obtaining the client's history and assessment?
- A. Identify the client's needs
- B. Start intravenous fluids
- C. Notify the provider
- D. Conduct a neurological assessment
Correct Answer: A
Rationale: Identifying the client's needs is essential to prioritize further interventions.
You may also like to solve these questions
A nurse is caring for a client who expresses anxiety about an upcoming surgery. What should the nurse do?
- A. Reassure the client that everything will be fine
- B. Ask the client to describe feelings
- C. Tell the client to stay positive
- D. Provide information about the surgery
Correct Answer: B
Rationale: Asking the client to describe their feelings allows the nurse to understand the specific concerns and anxieties the client is experiencing.
A nurse is assessing the IV infusion site of a client who reports pain at the site. The site is red and there is warmth along the course of the vein. What should the nurse do?
- A. Continue the infusion
- B. Increase the infusion rate
- C. Discontinue the infusion
- D. Apply a cold compress
Correct Answer: C
Rationale: The symptoms suggest phlebitis. The nurse should discontinue the infusion and may apply a warm compress.
A nurse is admitting a client who has meningococcal meningitis. What should the nurse do first?
- A. Initiate droplet precautions
- B. Start intravenous antibiotics
- C. Perform a complete assessment
- D. Notify the healthcare provider
Correct Answer: A
Rationale: Initiating droplet precautions is crucial to prevent the spread of infection, especially in cases of meningococcal meningitis.
A nurse is performing a focused assessment on a client who has a history of COPD and is experiencing dyspnea. Which of the findings should the nurse expect?
- A. Flaring of the nostrils
- B. Normal respiratory rate
- C. Clear lung sounds
- D. Decreased work of breathing
Correct Answer: A
Rationale: Flaring of the nostrils indicates increased respiratory effort, common in clients with dyspnea due to COPD.
A nurse is teaching a client about the use of a metered-dose inhaler (MDI). Which instruction should the nurse include in the teaching?
- A. Inhale the medication deeply for 3-5 seconds
- B. Exhale forcefully before inhaling
- C. Shake the MDI vigorously before use
- D. Hold the mouthpiece 2.5-5 cm (1-2 in) in front of the mouth
Correct Answer: A
Rationale: Inhaling the medication deeply for 3-5 seconds and holding the breath for 10 seconds after inhalation ensures effective medication delivery to the lungs.