Nokea
A nurse is caring for a client who is hemorrhaging and hypotensive from esophageal variceal bleeding. Which of the following actions should the nurse take first?
- A. Administer a vasopressor.
- B. Verify that the client has adequate IV access.
- C. Place the client in the Trendelenburg position.
- D. Prepare for endoscopic intervention.
Correct Answer: B
Rationale: The correct answer is B: Verify that the client has adequate IV access. This is the priority action because the client is hypotensive from hemorrhaging, indicating a need for immediate fluid resuscitation to stabilize their condition. Without adequate IV access, the nurse cannot administer life-saving fluids and medications. Administering a vasopressor (A) or preparing for endoscopic intervention (D) may be necessary later but addressing the hypotension is the priority. Placing the client in Trendelenburg position (C) is not recommended as it can increase intracranial pressure.
You may also like to solve these questions
A nurse is planning preventative strategies for a client who is at risk for pressure injuries. Which of the following actions should the nurse include in the plan?
- A. Apply moisturizer to damp skin after bathing.
- B. Massage bony prominences to improve circulation.
- C. Use cornstarch powder to keep skin dry.
- D. Position the client at a 90-degree angle in bed.
Correct Answer: A
Rationale: The correct answer is A: Apply moisturizer to damp skin after bathing. Moisturizing helps maintain skin integrity and hydration, reducing the risk of pressure injuries. When skin is damp, it is more receptive to hydration, which can prevent dryness and breakdown. Applying moisturizer also helps to maintain the skin's natural barrier function. Massaging bony prominences (choice B) can actually increase the risk of pressure injuries by causing friction and shearing forces. Using cornstarch powder (choice C) can lead to moisture buildup and increase the risk of skin breakdown. Positioning the client at a 90-degree angle in bed (choice D) is not a recommended preventive strategy for pressure injuries.
A nurse is planning care for a client who is scheduled for surgery and has a latex allergy. Which of the following actions should the nurse plan to take?
- A. Use only powder-free latex gloves.
- B. Place monitoring cords and tubes in a stockinette.
- C. Avoid using iodine-based antiseptics.
- D. Administer prophylactic antihistamines.
Correct Answer: B
Rationale: The correct answer is B: Place monitoring cords and tubes in a stockinette. This is important for the client with a latex allergy because stockinettes provide a barrier between the latex-containing materials and the client's skin, reducing the risk of allergic reactions. Using powder-free latex gloves (choice A) is a good practice, but it is not directly addressing the risk of exposure to latex for the client. Avoiding iodine-based antiseptics (choice C) is not necessary unless the client has a specific allergy to iodine. Administering prophylactic antihistamines (choice D) is not a standard practice for latex allergies and may not prevent an allergic reaction.
A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following findings should the nurse identify as a manifestation of type 1 diabetes?
- A. Ketones in the urine
- B. Weight gain
- C. Hypotension
- D. Decreased hunger
Correct Answer: A
Rationale: The correct answer is A: Ketones in the urine. In type 1 diabetes, the body cannot produce insulin, leading to high blood sugar levels and breakdown of fats for energy, resulting in ketones in the urine. Weight gain (B) is unlikely as type 1 diabetes is associated with weight loss. Hypotension (C) is not a typical manifestation. Decreased hunger (D) is more commonly seen in type 2 diabetes.
A nurse is providing teaching for a client who has neutropenia and is receiving chemotherapy. Which of the following client statements indicates an understanding of the teaching? (Select all that apply.)
- A. I will avoid crowds.
- B. I will wash my toothbrush weekly.
- C. I will take my temperature daily.
- D. I will eat plenty of fresh fruits and vegetables.
Correct Answer: A, C
Rationale: The correct answers are A and C. Neutropenia and chemotherapy increase the risk of infection. Avoiding crowds (A) reduces exposure to infectious agents. Taking temperature daily (C) helps detect early signs of infection. Washing toothbrush weekly (B) is important but daily is recommended. Eating fresh fruits and vegetables (D) is beneficial but may pose infection risk.
A nurse is planning care for a client who is receiving intermittent IV fluids via a peripherally inserted central catheter (PICC). Which of the following information should the nurse include in the clients plan of care?
- A. Assess the PICC infusion system systematically.
- B. Flush the line only before infusing medication.
- C. Use a sterile dressing for the catheter site every 7 days.
- D. Allow the catheter to remain uncapped when not in use.
Correct Answer: A
Rationale: The correct answer is A: Assess the PICC infusion system systematically. This is essential to monitor for signs of infection, occlusion, or dislodgement of the catheter. Regular assessment can help identify any issues early and prevent complications.
Summary:
B: Flushing the line only before infusing medication is incorrect as regular flushing is necessary to maintain catheter patency.
C: Using a sterile dressing every 7 days is incorrect as the dressing should be changed according to facility protocol or if it becomes soiled or loose.
D: Allowing the catheter to remain uncapped when not in use is incorrect as it can increase the risk of contamination and infection.