Nokea
A nurse is caring for a group of clients. In which of the following scenarios is the nurse acting as a client advocate?
- A. Encouraging a client to take pain medication despite refusal.
- B. Referring a client who has COPD for palliative care services.
- C. Discharging a client early to free up hospital beds.
- D. Withholding information about a new diagnosis to prevent distress.
Correct Answer: B
Rationale: The correct answer is B because referring a client with COPD for palliative care services demonstrates advocating for the client's best interest, ensuring they receive appropriate care to manage symptoms and improve quality of life. This action aligns with the nurse's role as a client advocate by advocating for the client's autonomy and well-being. In contrast, choices A, C, and D do not prioritize the client's best interests or rights. Choice A disregards the client's autonomy by encouraging medication against their wishes. Choice C prioritizes hospital efficiency over the client's needs. Choice D violates the client's right to informed decision-making by withholding essential information. Overall, choice B best exemplifies client advocacy in nursing practice.
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A nurse is caring for a client who has deep-vein thrombosis and is receiving heparin via continuous IV infusion. The clients weight is 80 kg (176.4 lb). Using the client information provided, which of the following actions should the nurse take?
- A. Increase the infusion rate.
- B. Administer protamine sulfate immediately.
- C. Stop the heparin infusion for 1 hr.
- D. Decrease the heparin dose.
Correct Answer: C
Rationale: The correct answer is C: Stop the heparin infusion for 1 hr. This is because the client's weight is crucial in determining the appropriate heparin dosage. Heparin is usually dosed based on the client's weight to prevent complications such as bleeding or clotting. In this case, the client's weight of 80 kg indicates a specific dose range for heparin. Stopping the infusion for 1 hour allows the nurse to reassess the client's condition and potentially adjust the heparin dosage to ensure it is safe and effective.
A: Increasing the infusion rate without proper assessment can lead to overdose and increased risk of bleeding.
B: Administering protamine sulfate is the antidote for heparin overdose, not indicated in this scenario.
D: Decreasing the heparin dose without assessment may result in inadequate anticoagulation and increased risk of clot formation.
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.
A nurse is providing teaching to a group of clients about the prevention of coronary artery disease. Which of the following information should the nurse include in the teaching?
- A. Walk 30 min daily at a comfortable pace.
- B. Avoid all sources of dietary fat.
- C. Increase sodium intake to prevent dehydration.
- D. Only exercise if experiencing symptoms.
Correct Answer: A
Rationale: Correct Answer: A: Walk 30 min daily at a comfortable pace.
Rationale: Regular physical activity, such as walking, helps prevent coronary artery disease by improving cardiovascular health, maintaining a healthy weight, and reducing stress. Walking for 30 minutes daily at a comfortable pace can improve circulation, lower blood pressure, and reduce the risk of developing heart disease.
Summary of other choices:
B: Avoiding all sources of dietary fat is not recommended as the body needs healthy fats for various functions.
C: Increasing sodium intake does not prevent coronary artery disease and can actually contribute to hypertension, a risk factor for the disease.
D: Only exercising when experiencing symptoms is not proactive in preventing coronary artery disease and may lead to missed opportunities for prevention.
A nurse notes that a clients eyes are protruding slightly from their orbits. Which of the following laboratory findings should the nurse expect?
- A. Decreased TSH levels
- B. Increased T4 levels
- C. Elevated calcium levels
- D. Low hemoglobin levels
Correct Answer: B
Rationale: The nurse should expect increased T4 levels in a client with slightly protruding eyes, known as exophthalmos, as it is a classic sign of hyperthyroidism, where the thyroid gland is overactive. Thyroid hormones, such as T4, are responsible for regulating metabolism, and elevated levels can lead to symptoms like exophthalmos. Decreased TSH levels (choice A) would actually be seen in primary hyperthyroidism due to negative feedback. Elevated calcium levels (choice C) are more indicative of hyperparathyroidism. Low hemoglobin levels (choice D) are not typically associated with exophthalmos or hyperthyroidism.
A nurse is caring for a client who is 24 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?
- A. Maintain abduction of the affected extremity.
- B. Position the client in high Fowlers position.
- C. Encourage the client to cross their legs at the ankles.
- D. Have the client bend forward at the waist while sitting.
Correct Answer: A
Rationale: The correct answer is A: Maintain abduction of the affected extremity. This is crucial post total hip arthroplasty to prevent dislocation. Abduction helps keep the hip joint stable and reduces the risk of the prosthesis slipping out of place. Choices B, C, and D are incorrect. High Fowler's position (B) is not necessary for this specific postoperative care. Crossing legs at the ankles (C) can lead to hip dislocation. Having the client bend forward at the waist (D) can also increase the risk of dislocation.