Nokea
A nurse is caring for an 82-year-old client in the ER who has an oral body temperature of 38.3°C (101°F), a pulse rate of 114/min, & a respiratory rate of 22/min. He is restless & his skin is warm. Which of the following are appropriate nursing interventions for this client? Select all.
- A. Obtain culture specimens before initiating antimicrobials
- B. Restrict the client's oral fluid intake
- C. Encourage the client to limit activity & rest
- D. Allow the client to shiver to dispel excess heat
- E. Assist the client with oral hygiene frequently
Correct Answer: A, C, E
Rationale: Correct Answer: A, C, E
Rationale:
A: Obtaining culture specimens before initiating antimicrobials is crucial to identify the specific pathogen causing the infection and guide appropriate treatment.
C: Encouraging the client to limit activity & rest helps conserve energy and promote recovery in the presence of infection.
E: Assisting the client with oral hygiene frequently helps prevent further infection and maintain oral health, which is important in the elderly population.
Incorrect Choices:
B: Restricting the client's oral fluid intake is not appropriate as hydration is essential, especially in the presence of fever and infection.
D: Allowing the client to shiver to dispel excess heat is not recommended as it can lead to increased metabolic demand and discomfort for the client.
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A nurse is caring for a client who is postoperative. Which of the following nursing interventions reduce the risk of thrombus development? Select all.
- A. Instruct the client not to use the Valsalva maneuver
- B. Apply elastic stockings
- C. Review lab values for total protein level
- D. Place pillows under the client's knees & lower extremities
- E. Assist the client to change position often
Correct Answer: B, E
Rationale: The correct answers are B and E. Applying elastic stockings helps promote circulation and prevent stasis, reducing the risk of thrombus formation. Assisting the client to change position often prevents prolonged immobility, which can lead to blood pooling and clot formation. Choice A is incorrect because the Valsalva maneuver can increase intra-abdominal pressure, potentially leading to venous stasis and thrombus formation. Choice C is irrelevant to thrombus prevention. Placing pillows under the client's knees and lower extremities (choice D) may promote comfort but does not directly reduce thrombus risk.
A nurse is preparing to administer 0.9% sodium chloride (0.9% NaCl) 250 mL IV to infuse over 30 minutes. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?
Correct Answer: 83
Rationale: To calculate the drip rate, we can use the formula: Drip rate = (Volume to be infused in gtt) / Time in minutes. In this case, the volume to be infused is 250 mL, and the time is 30 minutes. Convert 250 mL to drops: 250 mL x 10 gtt/mL = 2500 gtt. Now, divide 2500 gtt by 30 minutes to get 83.33 gtt/min. Since we can't administer a fraction of a drop, we round down to the nearest whole number, which is 83 gtt/min. This rate ensures the 0.9% NaCl solution is administered accurately over the specified time. Other choices are incorrect because they do not result from the correct calculation based on the given information.
A nurse who is admitting a client who has a fractured femur obtains a blood pressure reading of 140/94 mmHg. The client denies any history of hypertension. Which of the following actions should the nurse take next?
- A. Request a prescription for an antihypertensive medication
- B. Ask the client if she is having pain
- C. Request a prescription for an anti-anxiety medication
- D. Return in 30 minutes to recheck the client's BP
Correct Answer: B
Rationale: The correct answer is B. When a client with a fractured femur presents with an elevated blood pressure reading, it is important for the nurse to first assess if the client is in pain. Pain can cause an increase in blood pressure due to stress and sympathetic nervous system activation. Addressing pain management is crucial to providing holistic care and may help lower the blood pressure without the need for antihypertensive medications. Requesting an antihypertensive medication (choice A) without addressing the potential pain issue would not be appropriate at this time. Similarly, requesting an anti-anxiety medication (choice C) without further assessment would not address the underlying cause of the elevated blood pressure. Returning in 30 minutes to recheck the client's BP (choice D) is not as proactive as addressing the potential pain issue immediately.
A nurse is caring for a client who is receiving continuous enteral feedings. What is the highest priority intervention when the nurse suspects aspiration?
- A. Auscultate breath sounds.
- B. Stop the feeding.
- C. Obtain a chest x-ray.
- D. Initiate oxygen therapy.
Correct Answer: B
Rationale: The correct answer is B: Stop the feeding. Aspiration can lead to serious complications such as pneumonia. Stopping the feeding immediately is crucial to prevent further aspiration and minimize harm to the client. Auscultating breath sounds (choice A) is important but should be done after stopping the feeding. Obtaining a chest x-ray (choice C) may be necessary later for further evaluation but is not the highest priority in this situation. Initiating oxygen therapy (choice D) may be needed depending on the client's condition, but it is not the highest priority when aspiration is suspected.
A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy & unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on break. Which of the following actions should the nurse take?
- A. Remind the nurse that safe client care is a priority on the unit
- B. Ask others on the team whether they have observed the same behavior
- C. Report observations to the nurse manager on the unit
- D. Conclude that her coworker's fatigue is not her problem to solve
Correct Answer: C
Rationale: The correct action is to choose option C: Report observations to the nurse manager on the unit. This is the most appropriate course of action because it addresses the potential safety risk to patients due to the drowsy nurse's behavior. Reporting to the nurse manager ensures that the issue is escalated to someone in authority who can address it effectively, such as through a conversation with the drowsy nurse, adjusting their work schedule, or providing support if there are underlying issues causing the fatigue. Options A, B, and D are not as effective because reminding the nurse or asking others on the team may not lead to a resolution, and assuming the fatigue is not the nurse's problem to solve ignores the potential impact on patient safety.