Nokea
A nurse is caring for an older adult client who reports vaginal dryness and itching. Which of the following responses should the nurse make?
- A. These discomforts should decrease with time.'
- B. You should avoid intercourse to prevent injury to your vagina.'
- C. Women your age experience thickening of the vaginal tissue.'
- D. Your symptoms are likely due to decreasing estrogen levels.'
Correct Answer: D
Rationale: The correct answer is D: "Your symptoms are likely due to decreasing estrogen levels." This response is correct because vaginal dryness and itching are common symptoms of vaginal atrophy, which is often caused by decreased estrogen levels in older adult women. The nurse's acknowledgment and explanation of this physiological change can help the client understand the root cause of her symptoms and guide further discussion on appropriate treatment options, such as hormone therapy or vaginal moisturizers.
Choice A is incorrect because it dismisses the client's discomfort without addressing the underlying cause. Choice B is incorrect as it provides potentially harmful advice without addressing the issue. Choice C is incorrect as it inaccurately describes the condition of vaginal tissue in older women.
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A nurse is admitting a client who has arthritis pain and reports taking ibuprofen several times daily for 3 years. Which of the following tests should the nurse monitor?
- A. Serum calcium
- B. Stool for occult blood
- C. Fasting blood glucose
- D. Urine for white blood cells
Correct Answer: B
Rationale: The correct answer is B: Stool for occult blood. Long-term use of ibuprofen can lead to gastrointestinal bleeding, which may not always present with visible blood in the stool. Monitoring for occult blood helps detect this potential side effect early. Choices A, C, and D are not directly related to the adverse effects of ibuprofen use. Serum calcium is not typically affected by ibuprofen. Fasting blood glucose monitoring is more relevant for medications affecting glucose metabolism. Urine for white blood cells is not a common test for monitoring the side effects of ibuprofen.
A nurse is caring for a client who has a new onset of hyperglycemic hyperosmolar state (HHS). Which of the following interventions by the nurse is the highest priority?
- A. Administer Insulin.
- B. Teach the client about manifestations of HHS.
- C. Measure the client's urinary output.
- D. Initiate IV fluid replacement.
Correct Answer: D
Rationale: The correct answer is D: Initiate IV fluid replacement. In hyperglycemic hyperosmolar state (HHS), the client is severely dehydrated due to high blood glucose levels. IV fluid replacement is the highest priority to rehydrate the client and improve circulation. Administering insulin (A) is important but not the highest priority as fluid replacement takes precedence. Teaching the client about manifestations of HHS (B) is important for long-term management but not the immediate priority. Measuring urinary output (C) is important to assess renal function but not as critical as rehydrating the client.
A nurse is planning care for a client who has a new diagnosis of acute pancreatitis. Which of the following interventions should the nurse include in the plan of care?
- A. Administer antihypertensive medications.
- B. Maintain the client on NPO status.
- C. Place the client in a supine position.
- D. Monitor the client for hypercalcemia.
Correct Answer: B
Rationale: The correct answer is B: Maintain the client on NPO status. In acute pancreatitis, the pancreas is inflamed, leading to digestive enzyme release and potential autodigestion of pancreatic tissue. Keeping the client NPO (nothing by mouth) helps rest the pancreas by reducing stimulation of enzyme secretion. This allows the pancreas to heal and decreases the risk of further complications. Administering antihypertensive medications (A) is not typically a priority for acute pancreatitis. Placing the client in a supine position (C) may not directly impact the pancreatitis. Monitoring for hypercalcemia (D) is important in chronic pancreatitis but not typically a primary intervention in the acute phase.
A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 minutes after the infusion begins. Which of the following actions should the nurse take first?
- A. Collect a urine sample.
- B. Check the client's vital signs.
- C. Stop the infusion.
- D. Administer oxygen to the client.
Correct Answer: C
Rationale: The correct answer is C: Stop the infusion. The client's symptoms suggest a transfusion reaction, which could be life-threatening. Stopping the infusion is the priority to prevent further harm. Checking vital signs can wait, as immediate action is needed. Collecting a urine sample is not urgent in this situation. Administering oxygen is not indicated unless the client shows signs of respiratory distress, which is not mentioned in the scenario.
A nurse is providing teaching for a client who has diabetes mellitus about the self-administration of insulin. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will draw up the regular insulin into the syringe first.
- B. I will shake the NPH vial vigorously before drawing up the insulin.
- C. I will store prefilled syringes in the refrigerator with the needle pointed downward.
- D. I will insert the needle at a 15-degree angle.
Correct Answer: A
Rationale: Correct Answer: A - "I will draw up the regular insulin into the syringe first."
Rationale: Drawing up regular insulin before NPH prevents contamination. Regular insulin has a clear appearance, making it easier to detect any contamination. Drawing up NPH first can cause regular insulin to be contaminated if the same syringe is used. This statement demonstrates an understanding of the importance of preventing contamination and following proper insulin administration technique.
Summary of Incorrect Choices:
B: Shaking the NPH vial vigorously can cause air bubbles, affecting the accuracy of the dose.
C: Storing prefilled syringes in the refrigerator with the needle downward can cause leakage or contamination.
D: Inserting the needle at a 15-degree angle may not be appropriate for insulin injection, which typically requires a 90-degree angle for subcutaneous administration.