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A nurse notices a teenage patient with paraplegia in a wheelchair crying. What should the nurse's response be? What should the nurse respond to a crying teenage patient?
- A. I'll return later, and we can talk.
- B. Everything will be okay.
- C. Do you feel like crying helps?
- D. Would you like to be alone?
Correct Answer: A
Rationale: The correct answer is A: "I'll return later, and we can talk." This response acknowledges the patient's emotions, offers support, and opens the door for communication. It shows empathy and a willingness to engage with the patient. Choice B is dismissive and lacks empathy. Choice C may come across as invalidating the patient's feelings. Choice D may make the patient feel isolated. Overall, choice A is the most appropriate as it shows empathy, support, and a willingness to listen to the patient's concerns.
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A nurse is caring for a patient who is receiving IV fluids. The nurse notes that the IV site is red, warm, and painful. Which of the following actions should the nurse take first? What should the nurse do first for IV site issues?
- A. Slow the infusion rate.
- B. Apply a warm compress.
- C. Discontinue the IV line.
- D. Notify the provider.
Correct Answer: C
Rationale: The correct action for the nurse to take first is to discontinue the IV line (choice C). This is essential to prevent further complications such as infection or infiltration. Discontinuing the IV line will stop the source of the redness, warmth, and pain at the IV site. Slowing the infusion rate (choice A) would not address the underlying issue and could potentially worsen the situation. Applying a warm compress (choice B) could also exacerbate the symptoms if there is an infection. Notifying the provider (choice D) is important but should come after the immediate action of discontinuing the IV line to address the IV site issues promptly.
Nurse's Notes & Physical Examination
• The client arrived in the emergency department with complaints of fatigue, blurred vision, dizziness, and headache for the past two days. They report running out of blood glucose strips and insulin due to financial constraints. The client appears tired, is cooperative, and has a slightly dry mucous membrane. They are oriented to person, place, and time but seem concerned about their health status. The skin is warm and dry to the touch, with no visible rashes or lesions. Heart sounds are regular without murmurs; breath sounds are clear bilaterally. The abdomen is soft with no tenderness upon palpation. The client expresses anxiety about potential falls due to dizziness.
Vital Signs
• Blood Pressure: 120/72 mm Hg
• Temperature: 36.8° C (98.2° F)
• Pulse: 88/min
• Respirations: 20/min
Diagnostic Results
• Blood Glucose: 235 mg/dL (Reference range: 74-106 mg/dL)
• HbA1c: 8.4% (Target for diabetics: <7%)
• Hemoglobin: 14.2 g/dL (12-18 g/dL)
• Hematocrit: 42.6% (37-52%)
• WBC Count: 6000/mm³ (5000-10,000/mm³)
Provider's Prescriptions
• Increase glargine from 20 units to 25 units at bedtime.
• Continue other home medications as prescribed.
Scenario: A nurse is caring for a client admitted to the medical-surgical unit. The exhibits below detail the client's condition at different time points throughout the day. Review the exhibits and determine how the patient's condition evolves and whether it worsens or improves. The initial data is recorded at 0700 hrs, followed by subsequent observations at different times.
Based on the initial assessment and diagnostic results, what is the priority nursing intervention?
- A. Administer a bolus of IV fluids.
- B. Administer insulin.
- C. Administer oxygen therapy at 2 L/min via nasal cannula.
- D. Place the client on fall precautions and provide a bedside commode.
Correct Answer: A
Rationale: The correct answer is A: Administer a bolus of IV fluids. The priority nursing intervention is to address any immediate physiological needs identified in the initial assessment and diagnostic results. Administering IV fluids can help stabilize the client's fluid and electrolyte balance, ensuring proper circulation and organ function. This intervention takes precedence over the other options as it directly addresses a critical aspect of the client's condition. Administering insulin (choice B) may be necessary for managing specific conditions but is not the immediate priority. Oxygen therapy (choice C) may be beneficial, but if the client is in need of fluid resuscitation, addressing hypovolemia takes precedence. Fall precautions and providing a bedside commode (choice D) are important for safety but do not address the physiological needs identified in the initial assessment.
A nurse is caring for a patient who is receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider? Which lab value should the nurse report during chemotherapy?
- A. Hemoglobin 12 g/dL
- B. Platelet count 50,000/mm3
- C. WBC 8,000/mm3
- D. Serum creatinine 1.0 mg/dL
Correct Answer: B
Rationale: The correct answer is B: Platelet count 50,000/mm3. During chemotherapy, patients are at risk for developing thrombocytopenia, a condition characterized by low platelet count. Thrombocytopenia can lead to increased risk of bleeding and bruising. Therefore, a platelet count of 50,000/mm3 is concerning and should be reported to the provider for further evaluation and management.
A: Hemoglobin of 12 g/dL is within normal range and not typically a concern during chemotherapy.
C: WBC count of 8,000/mm3 is within normal range and may not be a priority during chemotherapy unless there are other concerning symptoms.
D: Serum creatinine of 1.0 mg/dL is within normal range and not directly related to chemotherapy effects on the patient's blood counts.
A nurse is caring for a child who is allergic to penicillin. Which prescription should the nurse verify with the provider?,Which prescription should be verified for a penicillin-allergic child?
- A. Amoxicillin-clavulanate.
- B. Gentamicin
- C. Erythromycin.
- D. Amphotericin
Correct Answer: A
Rationale: The correct answer is A: Amoxicillin-clavulanate. This is because amoxicillin-clavulanate belongs to the penicillin class of antibiotics and can potentially trigger an allergic reaction in a child who is allergic to penicillin. The nurse should verify this prescription with the provider to avoid any adverse reactions. Gentamicin (B) is an aminoglycoside antibiotic and is not related to penicillin. Erythromycin (C) is a macrolide antibiotic, which is also unrelated to penicillin. Amphotericin (D) is an antifungal medication and does not belong to the penicillin class. It is crucial for the nurse to ensure that the child does not receive any medication that could cause an allergic reaction due to their penicillin allergy.
A nurse is caring for a patient who is postoperative following a total hip arthroplasty. Which of the following actions should the nurse take to prevent hip dislocation? Which action prevents hip dislocation post-arthroplasty?
- A. Place the patient in high Fowler's position.
- B. Keep the patient's legs in adduction.
- C. Place a pillow between the patient's legs.
- D. Encourage the patient to flex the hip to 120 degrees.
Correct Answer: C
Rationale: Correct Answer: C: Place a pillow between the patient's legs.
Rationale: Placing a pillow between the patient's legs helps maintain proper alignment and prevents the hip from dislocating by keeping the legs in abduction. This position reduces the risk of internal rotation and adduction, which are common movements that can lead to hip dislocation post-arthroplasty.
Summary of Incorrect Choices:
A: Placing the patient in high Fowler's position does not directly address hip dislocation prevention.
B: Keeping the patient's legs in adduction increases the risk of hip dislocation.
D: Encouraging the patient to flex the hip to 120 degrees can also increase the risk of hip dislocation by placing stress on the hip joint.