Nokea
A nurse on a medical-surgical unit is caring for a group of clients. The nurse should identify that which of the following clients is at risk for hypovolemia?
- A. A client who has nasogastric suctioning
- B. A client who has chronic constipation
- C. A client who has syndrome of inappropriate antidiuretic hormone
- D. A client who took a toxic dose of sodium bicarbonate antacids
Correct Answer: A
Rationale: The correct answer is A. Nasogastric suctioning can lead to hypovolemia due to the loss of gastric fluids. Chronic constipation and syndrome of inappropriate antidiuretic hormone (SIADH) are not typically associated with hypovolemia. A toxic dose of sodium bicarbonate antacids may lead to metabolic alkalosis, not hypovolemia.
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A nurse offers pain medication to a client who is postoperative before ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles?
- A. Fidelity
- B. Autonomy
- C. Justice
- D. Beneficence
Correct Answer: D
Rationale: The correct answer is D: Beneficence. Beneficence involves actions intended to benefit the client, such as providing pain relief. In this scenario, the nurse is demonstrating beneficence by offering pain medication to alleviate the client's discomfort and promote their well-being. Fidelity (A) relates to being faithful to agreements and commitments, autonomy (B) refers to respecting a client's right to make decisions about their care, and justice (C) involves fairness and equal treatment. While these ethical principles are important in healthcare, the situation described primarily exemplifies the principle of beneficence.
During an admission history, a client tells a nurse that she is under a lot of stress. Which of the following physiological responses should the nurse expect to increase as a result of stress?
- A. Blood glucose - a common stress response.
- B. Intestinal peristalsis - should decrease due to stress.
- C. Peripheral blood vessels diameter - can vary in response to stress.
- D. Urine output - may vary but not a typical stress response.
Correct Answer: A
Rationale: The correct answer is A. Stress typically increases blood glucose levels due to the release of stress hormones like cortisol and adrenaline. Elevated blood glucose helps provide energy for the body to cope with the stressful situation. Choice B is incorrect because intestinal peristalsis, the movement of the intestines, is more likely to decrease under stress due to the 'fight or flight' response. Choice C is incorrect as peripheral blood vessels' diameter may vary in response to stress, with both constriction and dilation possible. Choice D is incorrect as urine output may increase or decrease depending on individual differences and the specific stress response, but it is not a typical or direct physiological response to stress.
A client is experiencing dyspnea and fatigue after completing morning care. Which of the following actions should the nurse include in the client's plan of care?
- A. Schedule rest periods during morning care.
- B. Discontinue morning care for 2 days.
- C. Perform all care as quickly as possible.
- D. Ask a family member to come in to bathe the client.
Correct Answer: A
Rationale: Scheduling rest periods during morning care is essential for managing dyspnea and fatigue in the client. This approach allows the client to pace themselves and catch their breath, promoting comfort and reducing symptoms. It is crucial to provide breaks to prevent overwhelming the client and exacerbating their symptoms. Discontinuing morning care for 2 days (choice B) is not a suitable solution as it does not address the underlying issue and may lead to neglect of essential care. Performing all care as quickly as possible (choice C) can worsen the client's symptoms and compromise their well-being by increasing stress and exertion. Asking a family member to bathe the client (choice D) does not address the need for rest periods during care and may not be feasible or appropriate in all situations.
The healthcare professional is caring for a client with a peripheral intravenous (IV) line that has infiltrated. What is the most appropriate initial action for the healthcare professional to take?
- A. Apply a warm compress to the affected area.
- B. Discontinue the IV and restart it in another site.
- C. Aspirate the IV line and flush it with normal saline.
- D. Notify the healthcare provider immediately.
Correct Answer: B
Rationale: The correct initial action when an IV line infiltrates is to discontinue the IV and restart it in another site. This is crucial to prevent complications such as tissue damage, phlebitis, and infection that can result from the infiltration. Applying a warm compress (Choice A) is not recommended as it can exacerbate the tissue damage caused by the infiltration. Aspirating the IV line and flushing it with normal saline (Choice C) is not appropriate for an infiltrated IV line as it does not address the main issue of infiltration. While notifying the healthcare provider (Choice D) is important, the immediate priority is to discontinue the infiltrated IV to prevent further harm and ensure proper delivery of fluids or medications.
A healthcare professional is assessing a client's oculomotor nerve functions. Which of the following actions should the healthcare professional take?
- A. Check the client's pupillary reaction to light
- B. Ask the client to read print from the Snellen chart
- C. Ask the client to identify different scents
- D. Use cotton to lightly touch the client's cornea
Correct Answer: A
Rationale: Checking the client's pupillary reaction to light is a key assessment to evaluate the oculomotor nerve function. The oculomotor nerve controls the pupil's constriction response to light. Choices B, C, and D are incorrect because testing vision with a Snellen chart, identifying scents, or touching the cornea are not specific assessments for oculomotor nerve function.