Nokea
A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should indicate to the nurse the need for immediate intervention?
- A. Axillary temperature 37.2°C (99°F)
- B. Apical pulse 100/min
- C. Respiratory rate 30/min
- D. Blood pressure 140/84 mm Hg
Correct Answer: C
Rationale: The correct answer is C. The nurse should prioritize airway and breathing in a client with a traumatic brain injury. An increased respiratory rate may indicate CO2 retention, which could lead to increased intracranial pressure. Choice A, axillary temperature 37.2°C (99°F), is within normal range and does not indicate an immediate need for intervention. Choice B, apical pulse 100/min, is slightly elevated but not as critical as respiratory distress in this scenario. Choice D, blood pressure 140/84 mm Hg, is also within normal limits and does not require immediate intervention compared to the respiratory rate.
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A nurse is caring for a client who has a peripherally inserted central catheter (PICC). For which of the following findings should the nurse notify the provider?
- A. The dressing was changed 7 days ago
- B. The circumference of the client's upper arm has increased by 10%
- C. The catheter has not been used in 8 hours
- D. The catheter has been flushed with 10 mL of sterile saline after medication use
Correct Answer: B
Rationale: An increase in the circumference of the client's upper arm by 10% could indicate deep vein thrombosis, which is a serious condition. Deep vein thrombosis can impede blood flow and potentially lead to life-threatening complications. Therefore, the nurse should notify the provider immediately about this finding. Choice A is not an immediate concern as PICC dressing changes are usually done every 7 days. Choice C is a normal finding as catheters may not be used for certain periods. Choice D is a correct procedure for maintaining catheter patency after medication use.
A nurse in a rural community center is providing education to a group of clients about first aid interventions for snake bites. Which of the following instructions should the nurse include in the teaching?
- A. Apply an ice pack directly to the affected area
- B. Immobilize the affected extremity with a splint
- C. Place a tourniquet above and below the affected area
- D. Elevate the affected extremity
Correct Answer: B
Rationale: The correct answer is to immobilize the affected extremity with a splint. This helps to slow the spread of venom by limiting movement. Applying an ice pack directly to the affected area (Choice A) is not recommended for snake bites as it could exacerbate tissue damage. Placing a tourniquet above and below the affected area (Choice C) is also not advised as it can lead to further complications. Elevating the affected extremity (Choice D) is not recommended for snake bites; keeping it below the level of the heart is more appropriate to reduce venom spread.
A nurse is teaching a group of assistive personnel (AP) about caring for clients who have Alzheimer's disease. Which of the following information should the nurse include in the teaching?
- A. Explain procedures clearly and concisely to the client before initiating care
- B. Encourage a client's engagement in appropriate activities to minimize emotional outbursts
- C. Speak calmly and at a moderate volume to a client who is unable to form words or sentences
- D. Provide supervision to prevent a client from becoming injured or lost
Correct Answer: D
Rationale: The correct answer is D because clients with Alzheimer's disease are at risk of wandering and becoming lost. Providing supervision helps prevent them from getting injured or lost. Choice A is incorrect because extensive details may overwhelm clients with Alzheimer's. Choice B is incorrect because limiting activities can lead to boredom and behavioral issues. Choice C is incorrect because speaking calmly and at a moderate volume helps to reduce agitation and confusion in clients with Alzheimer's.
A nurse is caring for a client who has dehydration. The client has a peripheral IV and a prescription for an infusion of 0.9% sodium chloride 1,000 mL with 40 mEq potassium chloride to infuse over 1 hr. Which of the following actions should the nurse take first?
- A. Teach the client to report findings of IV extravasation
- B. Evaluate the patency of the IV
- C. Consult with the pharmacist about the prescription
- D. Verify the prescription with the provider
Correct Answer: D
Rationale: The nurse's priority action should be to verify the prescription with the provider. This is crucial to prevent injury from fluid volume overload and rapid potassium infusion. Verifying the prescription ensures that the correct solution, rate, and additives are ordered according to the client's condition. While evaluating the patency of the IV is important, verifying the prescription takes precedence to ensure patient safety. Consulting with the pharmacist can be beneficial, but confirming the prescription with the provider is the immediate priority. Teaching the client about IV extravasation is important but is not the first action the nurse should take in this scenario.
A nurse is assessing a client who has a heart rate of 40/min. The client is diaphoretic and has chest pain. Which of the following medications should the nurse plan to administer?
- A. Lidocaine
- B. Adenosine
- C. Atropine
- D. Verapamil
Correct Answer: C
Rationale: The correct answer is C: Atropine. The client's presentation of bradycardia, diaphoresis, and chest pain indicates reduced cardiac output, requiring intervention to increase the heart rate. Atropine is used to treat bradycardia by blocking cardiac muscarinic receptors, thus inhibiting the parasympathetic nervous system. Lidocaine (Choice A) is used for ventricular arrhythmias, not bradycardia. Adenosine (Choice B) is used for supraventricular tachycardia, not bradycardia. Verapamil (Choice D) is a calcium channel blocker used for certain arrhythmias and hypertension, but not for increasing heart rate in bradycardia.