Nokea
A nurse is caring for a client who has gastroenteritis. Which of the following assessment findings should the nurse recognize as an indication that the client is experiencing dehydration?
- A. Distended jugular veins
- B. Increased blood pressure
- C. Decreased blood pressure
- D. Pitting, dependent edema
Correct Answer: C
Rationale: The correct answer is C: Decreased blood pressure. Dehydration in a client with gastroenteritis results in a decrease in blood volume, leading to decreased blood pressure. When the body loses fluids through vomiting and diarrhea, there is a reduction in circulating blood volume, causing a drop in blood pressure. This can result in symptoms such as dizziness, weakness, and increased heart rate as the body tries to compensate for the reduced blood volume. Distended jugular veins (A) are more indicative of heart failure, increased blood pressure (B) can occur in conditions like hypertension or stress, and pitting, dependent edema (D) is a sign of fluid overload, not dehydration.
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A nurse on the medical-surgical unit is caring for a client who has a seizure disorder. Which of the following interventions should the nurse include in the plan of care?
- A. Pad the upper two side rails of the client's bed.
- B. Keep a padded tongue blade at the client's bedside.
- C. Maintain peripheral IV access.
- D. Teach assistive personnel how to apply restraints.
Correct Answer: C
Rationale: The correct answer is C: Maintain peripheral IV access. This is important for clients with seizure disorders as they may require immediate administration of medications during or after a seizure. IV access allows for quick drug delivery.
Choice A is incorrect because padding the bed rails is not a standard intervention for seizure disorder.
Choice B is incorrect because a padded tongue blade is not necessary for managing seizures.
Choice D is incorrect because teaching assistive personnel to apply restraints is not a recommended intervention for clients with seizure disorders.
In summary, maintaining peripheral IV access is crucial for prompt medication administration during seizures, while the other choices are not directly related to managing seizures in this context.
A nurse is providing discharge teaching to a client who reports that they cannot afford their prescribed medication. Which of the following statements should the nurse make?
- A. I can arrange for a social worker to talk with you before you leave.'
- B. I can contact the occupational therapist to schedule a home visit.'
- C. Contact your pharmacy to inquire about a different medication.'
- D. You should ask your provider to prescribe a cheaper medication.'
Correct Answer: A
Rationale: The correct answer is A: "I can arrange for a social worker to talk with you before you leave." This option is the most appropriate as it addresses the client's financial constraints by offering assistance in accessing support services. A social worker can help the client explore options for medication assistance programs, financial aid, or community resources. Option B is incorrect as it does not directly address the client's medication affordability issue. Option C suggests switching medications without considering the client's specific needs. Option D places the burden on the client to navigate the healthcare system for cost-effective solutions. Option A is the best choice as it prioritizes addressing the client's financial barriers through appropriate referral and support.
A nurse on an intensive care unit is planning care for a client who has increased intracranial pressure following a head injury. Which of the following IV medications should the nurse plan to administer?
- A. Propranolol
- B. Dobutamine
- C. Mannitol
- D. Chlorpromazine
Correct Answer: C
Rationale: The correct answer is C: Mannitol. Mannitol is an osmotic diuretic that helps reduce cerebral edema by drawing water out of brain tissue. This helps decrease intracranial pressure in clients with head injuries. Propranolol (A) is a beta-blocker used for hypertension, not specifically for intracranial pressure. Dobutamine (B) is a beta-adrenergic agonist used for cardiac support, not for intracranial pressure. Chlorpromazine (D) is an antipsychotic medication and does not address intracranial pressure. In summary, Mannitol is the appropriate choice for managing increased intracranial pressure due to its osmotic diuretic properties.
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 a cervical spine injury and has a halo traction device in place. Which of the following actions should the nurse plan to take?
- A. Apply medicated powder under the vest to reduce itching.
- B. Move the client up and down in bed by holding onto the halo traction device.
- C. Ensure that there is space for one finger to fit between the vest and the client's skin.
- D. Locate or tighten the screws on the device as needed for the client's comfort.
Correct Answer: C
Rationale: The correct answer is C: Ensure that there is space for one finger to fit between the vest and the client's skin. This is important to prevent pressure ulcers and skin breakdown. Tight vest can lead to skin irritation. Applying medicated powder (A) may further irritate the skin. Moving the client by holding the halo traction device (B) can lead to dislodgement or injury. Locating or tightening screws (D) should only be done by healthcare providers to prevent complications.