Nokea
A nurse is preparing to administer vancomycin IV to an adult client. The client asks the nurse if the medication can be given 2 hr earlier. Which of the following statements should the nurse make?
- A. I can start the medication 30 minutes earlier.
- B. I can adjust the time and schedule for when its convenient for you.
- C. I can infuse the medication at a faster rate.
- D. I have up to 2 hours after the usual schedule time to give you this medication.
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Vancomycin is typically given at specific intervals to maintain therapeutic levels in the bloodstream.
2. Giving the medication 2 hours earlier may lead to suboptimal drug levels.
3. Answer D allows flexibility within the recommended dosing schedule.
4. Answers A, B, and C compromise the effectiveness and safety of vancomycin administration.
5. Option D ensures the medication is given within an appropriate timeframe.
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An emergency room nurse is assessing a client who has asthma and difficulty breathing. Which of the following findings should indicate to the nurse that the client is experiencing status asthmaticus?
- A. Mild wheezing
- B. Use of accessory muscles
- C. Decreased respiratory rate
- D. Productive cough
Correct Answer: B
Rationale: The correct answer is B: Use of accessory muscles. In status asthmaticus, a severe and life-threatening asthma exacerbation, the client's airways are severely constricted, leading to inadequate air exchange. The use of accessory muscles (such as intercostal and supraclavicular muscles) indicates significant respiratory distress as the body tries to compensate for the difficulty in breathing. Mild wheezing (choice A) may be present in asthma but does not necessarily indicate status asthmaticus. Decreased respiratory rate (choice C) is not consistent with the increased respiratory effort seen in status asthmaticus. Productive cough (choice D) is more indicative of conditions such as bronchitis or pneumonia, not necessarily status asthmaticus.
A nurse is planning care for a client who had a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care?
- A. Encourage the client to ambulate independently.
- B. Turn the client by log rolling with a turning sheet.
- C. Position the client in a high Fowlers position.
- D. Apply a heating pad to the lower back.
Correct Answer: B
Rationale: The correct answer is B: Turn the client by log rolling with a turning sheet. This is the correct intervention because after a lumbar laminectomy, it is crucial to protect the surgical site and avoid bending or twisting the spine. Log rolling with a turning sheet helps maintain proper alignment and prevent injury to the surgical area.
Choice A is incorrect because encouraging the client to ambulate independently may put stress on the surgical area. Choice C is incorrect as positioning the client in a high Fowler's position may also strain the spine. Choice D is incorrect because applying a heating pad to the lower back can increase the risk of burns and should be avoided near a surgical site.
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.
A nurse is providing teaching about dietary options for a client who has cholelithiasis. Which of the following statements should the nurse include in the teaching?
- A. Avoid high-fat cuts of meat.
- B. Increase your intake of fried foods.
- C. Consume dairy products at every meal.
- D. Eat large meals to avoid frequent digestion.
Correct Answer: A
Rationale: The correct answer is A: Avoid high-fat cuts of meat. Cholelithiasis is the formation of gallstones, often related to high-fat diets. High-fat cuts of meat can trigger gallbladder contractions, leading to pain. The rationale is to reduce fat intake to prevent further gallstone formation. Choices B, C, and D are incorrect. B: Increasing fried foods can exacerbate symptoms due to their high-fat content. C: Consuming dairy products at every meal is not recommended as some dairy products can be high in saturated fats. D: Eating large meals can overload the digestive system, potentially leading to gallbladder discomfort.
A nurse is preparing a teaching plan for a client who is starting to receive hemodialysis for chronic kidney disease. Which of the following instructions should the nurse include in the teaching?
- A. Increase your intake of protein to 1 to 1.5 grams per kilogram per day.
- B. Reduce your fluid intake to 1L per day.
- C. Increase sodium intake to prevent hypotension.
- D. Monitor blood glucose levels daily.
Correct Answer: A
Rationale: The correct answer is A: Increase your intake of protein to 1 to 1.5 grams per kilogram per day. This is because patients undergoing hemodialysis often experience protein loss during the process. Adequate protein intake helps maintain muscle mass and supports overall health. Option B is incorrect as fluid restriction is typically recommended for patients on hemodialysis due to impaired fluid removal by the kidneys. Option C is incorrect as increasing sodium intake can lead to fluid retention and exacerbate hypertension, a common complication in chronic kidney disease. Option D is not directly related to hemodialysis and is more pertinent to diabetes management.