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A nurse is planning care for a client who has a seizure disorder. Which of the following equipment should the nurse place in the client's room?
- A. NG tube
- B. Tongue blade
- C. Wrist restraints
- D. Oral airway
Correct Answer: D
Rationale: The correct answer is D: Oral airway. During a seizure, a client may experience difficulty breathing due to their airway being obstructed. Placing an oral airway helps maintain a clear airway, ensuring adequate oxygenation. NG tube (A) is not relevant to managing seizures. Tongue blade (B) can cause injury during a seizure. Wrist restraints (C) are not appropriate and can increase the risk of injury.
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A nurse is reviewing the medical record of a client who has acute gout. The nurse should expect an increase in which of the following laboratory results?
- A. Intrinsic factor
- B. Uric acid
- C. Chloride level
- D. Creatinine kinase
Correct Answer: B
Rationale: The correct answer is B: Uric acid. In acute gout, there is an accumulation of uric acid crystals in the joints, leading to inflammation and pain. As a result, the uric acid levels in the blood increase. Monitoring uric acid levels helps in diagnosing and managing gout.
Explanation for other choices:
A: Intrinsic factor - Intrinsic factor is related to vitamin B12 absorption, not gout.
C: Chloride level - Chloride level is not directly impacted by acute gout.
D: Creatinine kinase - Creatinine kinase is an enzyme related to muscle breakdown, not specifically affected by gout.
A nurse in the PACU is caring for a client. Which of the following assessments is the nurse's priority?
- A. Level of consciousness
- B. Surgical site
- C. Pain level
- D. Respiratory status
Correct Answer: D
Rationale: The correct answer is D: Respiratory status. In the PACU, ensuring adequate oxygenation and ventilation is crucial for the client's immediate postoperative recovery. Monitoring respiratory status helps prevent complications like hypoxia or respiratory distress. Assessing the airway, breathing rate, depth, and oxygen saturation takes precedence over other assessments. Level of consciousness (A) is important but can be affected by respiratory issues. Surgical site (B) assessment is important but not an immediate priority. Pain level (C) is important but can be managed once respiratory status is stable. Summary: Respiratory status is the priority as it directly impacts the client's immediate well-being and recovery.
A nurse is caring for a client immediately following a lumbar puncture. Which of the following actions should the nurse take?
- A. Limit the client's fluid intake.
- B. Measure blood glucose every 2 hr.
- C. Instruct the client to expect tingling in their extremities.
- D. Instruct the client to lie flat.
Correct Answer: D
Rationale: The correct answer is D: Instruct the client to lie flat. This is important to prevent post-lumbar puncture headache by promoting the closure of the dural puncture site. Lying flat helps reduce the risk of cerebrospinal fluid leakage and subsequent headache. Limiting fluid intake (A) is not necessary post-lumbar puncture. Monitoring blood glucose (B) is not directly related to lumbar puncture care. Expecting tingling in extremities (C) is not a common post-lumbar puncture symptom.
A nurse is assessing a client who has a history of type 2 diabetes mellitus. The nurse should identify which of the following findings as an indication of a microvascular complication?
- A. Peripheral neuropathy
- B. Hypertension
- C. Retinopathy
- D. Stroke
Correct Answer: C
Rationale: The correct answer is C: Retinopathy. In type 2 diabetes, prolonged high blood sugar levels can damage small blood vessels in the retina, leading to retinopathy, a microvascular complication affecting the eyes. This can result in vision problems or even blindness. Peripheral neuropathy (A) is a macrovascular complication affecting the nerves, not the microvasculature. Hypertension (B) is a common comorbidity but not a direct microvascular complication. Stroke (D) is a macrovascular complication involving large blood vessels in the brain, not microvasculature. Thus, the nurse should identify retinopathy (C) as the correct indication of a microvascular complication in a client with type 2 diabetes mellitus.
A nurse is teaching a client who has AIDS and wishes to continue self-care at home despite living alone. Which of the following actions by the nurse demonstrates client advocacy?
- A. Instruct the client to avoid eating raw vegetables.
- B. Remind the client of the importance of medication adherence.
- C. Tell the client to avoid places where there are large crowds of people.
- D. Initiate a referral for the client to a home health agency.
Correct Answer: B
Rationale: Correct Answer: B. Remind the client of the importance of medication adherence.
Rationale: Ensuring medication adherence is crucial for managing AIDS. By reminding the client of this, the nurse advocates for the client's health and well-being. This action promotes the client's self-care and disease management, ultimately empowering the client to take control of their health.
Summary of other choices:
A: Instructing the client to avoid eating raw vegetables is not directly related to client advocacy in the context of AIDS management.
C: Telling the client to avoid large crowds does not directly address the client's ability to continue self-care at home.
D: Initiating a referral to a home health agency may be helpful but does not directly demonstrate client advocacy in this scenario.