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A nurse is caring for a client who was admitted with bleeding esophageal varices and has an esophagogastric balloon tamponade with a Sengstaken-Blakemore tube to control the bleeding. Which of the following actions should the nurse take?
- A. Provide frequent oral and nares care.
- B. Monitor the client's oxygen levels.
- C. Administer intravenous antibiotics.
- D. Remove the tube immediately after 24 hours.
Correct Answer: A
Rationale: The correct answer is A: Provide frequent oral and nares care. This is important because the Sengstaken-Blakemore tube can cause discomfort and irritation to the oral and nasal mucosa, leading to potential complications such as infection or pressure ulcers. Providing frequent oral and nares care helps prevent these complications and ensures the client's comfort.
Choice B is incorrect because monitoring oxygen levels is not directly related to the care of a client with a Sengstaken-Blakemore tube.
Choice C is incorrect because administering intravenous antibiotics is not a routine intervention for a client with a Sengstaken-Blakemore tube unless there is a specific indication for infection.
Choice D is incorrect because the Sengstaken-Blakemore tube should not be removed immediately after 24 hours. The timing of removal should be determined based on the client's condition and the healthcare provider's orders.
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A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority?
- A. CD4-T-cell count 180 cells/mm3
- B. White blood cell count 10,000/mm3
- C. Hemoglobin 12.5 g/dL
- D. Platelet count 200,000/mm3
Correct Answer: A
Rationale: The correct answer is A: CD4-T-cell count 180 cells/mm3. In HIV, monitoring CD4-T-cell count is crucial as it reflects the immune system's ability to fight infections. A low CD4 count indicates immunosuppression, increasing the risk of opportunistic infections. Therefore, it is the nurse's priority to monitor and ensure the CD4 count remains above critical levels to prevent complications.
Other choices are incorrect because:
B: White blood cell count is important but not as specific to HIV management.
C: Hemoglobin level is important for assessing anemia but not a priority in HIV care.
D: Platelet count is important for clotting but not directly related to HIV progression.
A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify?
- A. Electrocardiogram
- B. Chest X-ray
- C. Echocardiogram
- D. MRI of the chest
Correct Answer: D
Rationale: The correct answer is D. MRI of the chest should be clarified because the magnetic field can interfere with the function of the pacemaker, potentially causing harm to the patient. An electrocardiogram, chest X-ray, and echocardiogram are safe imaging tests that do not interfere with the pacemaker. Therefore, D is the correct answer that should be clarified to ensure patient safety.
A nurse is providing discharge teaching to a client who has a new arteriovenous fistula in the right forearm. Which of the following manifestations should the nurse include in the teaching as a possible indication of venous insufficiency?
- A. Cold and numbness distal to the fistula site
- B. Pallor and numbness distal to the fistula site
- C. Redness and warmth at the fistula site
- D. Pain in the fistula site
Correct Answer: B
Rationale: The correct answer is B: Pallor and numbness distal to the fistula site. This is indicative of venous insufficiency in a client with an arteriovenous fistula. Venous insufficiency occurs when there is inadequate venous return to the heart, leading to decreased blood flow and oxygen delivery to the tissues. Pallor and numbness are signs of decreased blood flow, which can occur when the fistula is not functioning properly. Cold and numbness (choice A) may indicate arterial insufficiency, not venous. Redness and warmth (choice C) are signs of inflammation, not venous insufficiency. Pain in the fistula site (choice D) may be due to other reasons like infection or nerve compression, not necessarily venous insufficiency.
A rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take?
- A. Encourage the client to discuss their feelings
- B. Establish a plan of care with the client that sets attainable goals
- C. Increase the frequency of physical therapy sessions
- D. Allow the client to set the schedule for rehabilitation
Correct Answer: B
Rationale: The correct answer is B: Establish a plan of care with the client that sets attainable goals. This is because involving the client in setting realistic goals can empower them and increase motivation for rehabilitation. By collaborating with the client, the nurse can address the client's needs and preferences, leading to a more personalized and effective rehabilitation plan. Encouraging the client to actively participate in their care promotes autonomy and fosters a sense of control over their situation.
Other choices are incorrect:
A: Encouraging the client to discuss their feelings is important, but it may not directly address the need for a structured plan of care with attainable goals.
C: Increasing the frequency of physical therapy sessions may be overwhelming for the client and not address the underlying issue of lack of motivation.
D: Allowing the client to set the schedule for rehabilitation may not provide the structure and guidance needed for effective rehabilitation.
A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect?
- A. Cyanosis
- B. Agitation
- C. Hypotension
- D. Dizziness
Correct Answer: B
Rationale: The correct answer is B: Agitation. During an asthma attack, hypoxemia can lead to decreased oxygen supply to the brain, causing agitation due to hypoxia. Cyanosis (A) is a bluish discoloration of the skin and mucous membranes, indicating severe hypoxemia. Hypotension (C) is not typically associated with hypoxemia in asthma. Dizziness (D) is more commonly seen in conditions like hyperventilation rather than hypoxemia. In summary, agitation is the most likely manifestation of hypoxemia during an asthma attack due to decreased oxygen supply to the brain.