Nokea
A nurse is caring for a client who has a new onset of hyperglycemic hyperosmolar state (HHS). Which of the following interventions by the nurse is the highest priority?
- A. Administer Insulin.
- B. Teach the client about manifestations of HHS.
- C. Measure the client's urinary output.
- D. Initiate IV fluid replacement.
Correct Answer: D
Rationale: The correct answer is D: Initiate IV fluid replacement. In hyperglycemic hyperosmolar state (HHS), the client is severely dehydrated due to high blood glucose levels. IV fluid replacement is the highest priority to rehydrate the client and improve circulation. Administering insulin (A) is important but not the highest priority as fluid replacement takes precedence. Teaching the client about manifestations of HHS (B) is important for long-term management but not the immediate priority. Measuring urinary output (C) is important to assess renal function but not as critical as rehydrating the client.
You may also like to solve these questions
A nurse is caring for a client who has cervical cancer and is receiving internal radiation therapy. Which of the following actions should the nurse take?
- A. Check if the radioactive device is in the correct position.
- B. Limit time for visitors to 2 hours per day.
- C. Ask visitors to remain 3 feet from the client.
- D. Keep lead-lined aprons in the client's room.
Correct Answer: A
Rationale: The correct action for the nurse to take is to check if the radioactive device is in the correct position. This is crucial to ensure that the radiation therapy is being delivered accurately and effectively. By verifying the position of the radioactive device, the nurse can prevent potential harm to the client and ensure the success of the treatment.
Choice B is incorrect because limiting visitors' time does not directly relate to the safety and effectiveness of the radiation therapy. Choice C is incorrect as asking visitors to remain 3 feet away does not address the primary concern of verifying the device's position. Choice D is also incorrect as lead-lined aprons are typically used by healthcare providers during procedures, not by the client.
A nurse is planning care for a client who has dementia and a history of wandering. Which of the following actions should the nurse plan to implement?
- A. Move client to a double room.
- B. Use chemical restraints at bedtime.
- C. Use a bed alarm.
- D. Encourage participation in activities that provide excessive stimulation.
Correct Answer: C
Rationale: The correct answer is C: Use a bed alarm. This option promotes client safety by alerting the nurse when the client attempts to leave the bed, reducing the risk of wandering. Moving the client to a double room (A) does not address the wandering behavior. Using chemical restraints (B) is unethical and can lead to adverse effects. Encouraging excessive stimulation (D) can escalate agitation and wandering behavior.
A nurse is caring for a client who has a full-thickness burn. Which of the following actions should the nurse take?
- A. Implement fluid restriction.
- B. Provide humidified oxygen.
- C. Administer antibiotic medications.
- D. Administer acyclovir orally.
Correct Answer: B
Rationale: The correct answer is B: Provide humidified oxygen. Full-thickness burns can compromise the client's ability to breathe due to airway swelling and damage. Providing humidified oxygen helps support respiratory function by improving oxygenation and reducing the risk of hypoxia. Implementing fluid restriction (A) is not appropriate as burn patients typically require increased fluid intake to prevent dehydration. Administering antibiotic medications (C) may be necessary to prevent infection but is not the priority in this scenario. Administering acyclovir orally (D) is used to treat viral infections, not full-thickness burns.
A nurse working in the emergency department is caring for a client who has a burn injury. After securing the client's airway, which of the following interventions should the nurse take first?
- A. Administer analgesic medication.
- B. Increase the room temperature.
- C. Cleanse the client's wounds.
- D. Start an IV with a large bore needle.
Correct Answer: D
Rationale: The correct answer is D: Start an IV with a large bore needle. This intervention is crucial for fluid resuscitation in burn victims to prevent hypovolemic shock. Starting an IV allows for prompt administration of fluids and medications. Administering analgesics (A) can wait until after fluids are started. Increasing room temperature (B) is not a priority. Cleansing wounds (C) can be delayed until the patient is stabilized. Starting an IV is more urgent than other interventions in the initial management of burn injuries.
A nurse is planning to withdraw medication from an ampule to prepare for an injection. Which of the following actions should the nurse plan to take?
- A. Withdraw the medication from the ampule using a needleless system.
- B. Place a paper towel around the ampule's neck to break off the top with both hands.
- C. Dispose of the top of the ampule in a sharps container.
- D. Expel air into the ampule to aspirate air bubbles.
Correct Answer: B
Rationale: The correct answer is B: Place a paper towel around the ampule's neck to break off the top with both hands. This method helps prevent injury as the paper towel provides grip and protection. Breaking the ampule's top with both hands reduces the risk of glass shards. Using a needleless system (A) is not necessary for breaking an ampule. Disposing the top in a sharps container (C) is important, but it is not the immediate action for withdrawing medication. Expelling air into the ampule (D) is unnecessary and may introduce air bubbles into the medication.