Nokea
A nurse on the medical-surgical unit is caring for a client who has a seizure disorder. Which of the following interventions should the nurse include in the plan of care?
- A. Pad the upper two side rails of the client's bed.
- B. Keep a padded tongue blade at the client's bedside.
- C. Maintain peripheral IV access.
- D. Teach assistive personnel how to apply restraints.
Correct Answer: C
Rationale: The correct answer is C: Maintain peripheral IV access. This is important for clients with seizure disorders as they may require immediate administration of medications during or after a seizure. IV access allows for quick drug delivery.
Choice A is incorrect because padding the bed rails is not a standard intervention for seizure disorder.
Choice B is incorrect because a padded tongue blade is not necessary for managing seizures.
Choice D is incorrect because teaching assistive personnel to apply restraints is not a recommended intervention for clients with seizure disorders.
In summary, maintaining peripheral IV access is crucial for prompt medication administration during seizures, while the other choices are not directly related to managing seizures in this context.
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A nurse is caring for a client who has moderate Alzheimer's disease. During weekly home visits, the nurse notices that the client's caregiver is tired, irritable, and impatient with the client. Which of the following actions should the nurse recommend to the caregiver?
- A. Pursue local protective services.
- B. Consider respite care services.
- C. Take a nonprescription sleeping medication.
- D. Contact hospice services for end-of-life care.
Correct Answer: B
Rationale: The correct answer is B: Consider respite care services. Respite care provides temporary relief to caregivers, allowing them to take a break from their caregiving responsibilities. This is important for the caregiver's well-being and can prevent burnout. It also ensures the client receives continuous care. Pursuing local protective services (A) may escalate the situation unnecessarily. Taking nonprescription sleeping medication (C) is not a long-term solution and may have adverse effects. Contacting hospice services for end-of-life care (D) is premature and not appropriate for a client with moderate Alzheimer's disease.
A nurse is providing teaching for a client who is taking isoniazid (INH) for tuberculosis. Which of the following statements by the client indicates an understanding of the teaching?
- A. I plan to take this medication for 1 week.'
- B. I should take an antacid with each dose of this medication.'
- C. This medication may cause my blood pressure to increase.'
- D. I will have my liver function tested while I am taking this medication.'
Correct Answer: D
Rationale: The correct answer is D: "I will have my liver function tested while I am taking this medication." This answer demonstrates understanding because isoniazid (INH) is known to potentially cause liver toxicity. Regular monitoring of liver function is essential to detect any adverse effects early. Option A is incorrect as INH treatment typically lasts for several months, not just 1 week. Option B is incorrect as antacids can decrease the absorption of INH. Option C is incorrect as INH does not typically cause an increase in blood pressure.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following nursing actions isn't appropriate?
- A. Monitor serum blood glucose during infusion.
- B. Obtain the client's weight daily.
- C. Infuse 0.9% sodium chloride if the solution is not available.
- D. Verify the solution with another RN prior to infusion.
Correct Answer: C
Rationale: Correct Answer: C - Infuse 0.9% sodium chloride if the solution is not available.
Rationale: TPN is a specialized form of nutrition that must be administered precisely as prescribed to prevent complications. Infusing 0.9% sodium chloride instead of the prescribed TPN solution can lead to imbalanced nutrient intake and electrolyte disturbances. It is crucial to follow the prescribed TPN regimen accurately to meet the client's specific nutritional needs.
Incorrect Choices:
A: Monitoring serum blood glucose during infusion is appropriate to ensure the client's glycemic control while on TPN.
B: Obtaining the client's weight daily is important to assess fluid status and adjust the TPN prescription as needed.
D: Verifying the TPN solution with another RN prior to infusion is a standard safety practice to prevent errors in administration.
A nurse is caring for a client who has heart failure. Which of the following findings indicate the client is at risk for developing complications?
- A. Dysrhythmias
- B. Respiratory alkalosis
- C. Acute kidney injury
- D. Fluid volume deficit
Correct Answer: A
Rationale: The correct answer is A, dysrhythmias. In heart failure, the heart's inability to pump effectively can lead to electrical disturbances causing dysrhythmias, which can be life-threatening. Dysrhythmias can result in decreased cardiac output, further exacerbating heart failure. Respiratory alkalosis (B) is not a direct complication of heart failure. Acute kidney injury (C) can occur due to decreased cardiac output, leading to decreased renal perfusion, but it is not a direct risk factor for complications in heart failure. Fluid volume deficit (D) is a common finding in heart failure due to fluid retention, but it is not a direct risk for complications like dysrhythmias.
A nurse is providing teaching to a client who is considering a total hip arthroplasty. The client asks the nurse, 'What happens if I need a blood transfusion during my surgery?' Which of the following statements should the nurse make?
- A. You will need to choose a family member to donate blood, instead of a friend.'
- B. This surgery has minimal blood loss, so you will not require a transfusion.'
- C. You can donate your own blood a few weeks prior to this surgery.'
- D. Using screened donor blood during a transfusion makes it unlikely that you would have an infusion reaction.'
Correct Answer: C
Rationale: The correct answer is C: "You can donate your own blood a few weeks prior to this surgery." This is the best option because it addresses the client's concern about needing a blood transfusion during surgery by suggesting an effective proactive measure. Donating your own blood before surgery, known as autologous donation, ensures that you have your own blood available if needed, reducing the risk of transfusion reactions and complications. It allows for a personalized and safe option in case of blood loss during the procedure.
As for the other options:
A: This statement does not provide relevant information about blood transfusions.
B: This statement is inaccurate as total hip arthroplasty can result in significant blood loss requiring a transfusion.
D: While using screened donor blood reduces the risk of infusion reactions, it does not address the client's specific concern about needing a transfusion during surgery.
Therefore, option C is the most appropriate response as it directly addresses the client's query and offers a practical solution.