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A nurse is caring for a client who is in severe pain. Which of the following questions should the nurse ask first?
- A. How severe is your pain on a scale of 1 to 10?
- B. Where is your pain located?
- C. What medication are you taking for the pain?
- D. When did the pain start?
Correct Answer: B
Rationale: The correct answer is B: 'Where is your pain located?' When a client is experiencing severe pain, determining the location of the pain is crucial as it helps the nurse identify potential causes and select appropriate interventions. Option A may be important but assessing the location of pain takes precedence as it can provide valuable information for immediate management. Option C focuses on the current treatment, which is important but not the first priority. Option D, knowing when the pain started, is relevant but does not help in immediate pain management.
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A client has developed phlebitis at the IV site. What is the most appropriate next step?
- A. Apply a warm compress over the IV site
- B. Notify the provider and discontinue the IV infusion
- C. Increase the IV flow rate to clear the blockage
- D. Elevate the extremity and apply an ice pack
Correct Answer: B
Rationale: Phlebitis, inflammation of a vein, is a complication that requires prompt action. The most appropriate next step is to discontinue the IV infusion and notify the healthcare provider. Applying a warm compress, increasing the IV flow rate, or applying an ice pack are not appropriate interventions for phlebitis. Warm compresses may worsen inflammation, increasing the IV flow rate could exacerbate the condition, and ice packs are not recommended for phlebitis.
When caring for a client experiencing delirium, which of the following is essential?
- A. Controlling behavioral symptoms with low-dose psychotropics
- B. Identifying the underlying causative condition or illness
- C. Manipulating the environment to increase orientation
- D. Decreasing or discontinuing all previously prescribed medications
Correct Answer: B
Rationale: When caring for a client experiencing delirium, it is essential to identify the underlying causative condition or illness. Delirium can be caused by various factors such as infections, medication side effects, dehydration, or underlying health conditions. By identifying the root cause, appropriate treatment can be provided. Controlling behavioral symptoms with low-dose psychotropics (Choice A) may be considered in some cases but is not the primary essential step. Manipulating the environment to increase orientation (Choice C) can help manage symptoms but does not address the underlying cause. Decreasing or discontinuing all previously prescribed medications (Choice D) should only be done under medical supervision, as some medications may be necessary for the client's well-being.
A healthcare professional is planning care for a client who has a prescription for mechanical restraints. Which of the following interventions should the healthcare professional include in the plan?
- A. Document the client's status every 60 minutes.
- B. Provide a staff member to stay with the client continuously.
- C. Measure vital signs every 4 hours.
- D. Obtain a prescription for the restraints every 8 hours.
Correct Answer: B
Rationale: When a client has a prescription for mechanical restraints, it is essential to provide continuous monitoring for their safety and to observe any behavioral changes. Having a staff member stay with the client continuously allows for immediate intervention if needed. Documenting the client's status every 60 minutes (Choice A) may not provide real-time monitoring, which is crucial in this situation. While measuring vital signs every 4 hours (Choice C) is important, continuous observation takes precedence in this scenario. Obtaining a prescription for the restraints every 8 hours (Choice D) is not a necessary intervention once the initial prescription is in place.
A client with a tracheostomy is exhibiting signs of respiratory distress. What is the first action the nurse should take?
- A. Increase the suction setting on the ventilator
- B. Suction the tracheostomy
- C. Notify the physician immediately
- D. Encourage deep breathing exercises
Correct Answer: B
Rationale: The correct first action for a client with a tracheostomy exhibiting signs of respiratory distress is to suction the tracheostomy. This helps clear the airway and improve breathing. Increasing the suction setting on the ventilator is not appropriate as the issue may be related to secretions that need to be directly removed. Notifying the physician should come after providing immediate nursing interventions. Encouraging deep breathing exercises is not suitable when the client is in respiratory distress and needs prompt intervention.
What are the signs and symptoms of fluid overload?
- A. Edema, shortness of breath, weight gain
- B. High blood pressure and jugular venous distention
- C. Low blood pressure and cyanosis
- D. Tachycardia and dizziness
Correct Answer: A
Rationale: The correct signs and symptoms of fluid overload include edema, shortness of breath, and weight gain. Edema is the abnormal accumulation of fluid causing swelling, shortness of breath can occur due to fluid accumulating in the lungs, and weight gain is often seen as a result of excess fluid retention. Choices B, C, and D are incorrect because high blood pressure and jugular venous distention are more indicative of conditions like heart failure, while low blood pressure and cyanosis are seen in conditions like shock or poor perfusion. Tachycardia and dizziness are not typical signs of fluid overload.