Nokea
A nurse on the medical-surgical unit is receiving reports on four clients. Which of the following clients should the nurse assess first?
- A. A client who is receiving warfarin and has an INR of 3.3
- B. A client who has acute kidney injury, creatinine 4 mg/dL, and BUN 52 mg/dL
- C. A client who had an NG tube inserted 6 hours ago and has abdominal distention
- D. A client who is 4 hours postoperative following a thyroidectomy and reports fullness in the throat
Correct Answer: D
Rationale: The client who is 4 hours postoperative following a thyroidectomy and reports fullness in the throat should be assessed first. This client may be experiencing airway obstruction due to hematoma or swelling, making it a priority. Options A, B, and C have concerning findings as well, but airway compromise takes precedence over other issues.
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A nurse is assessing a client who has diabetes insipidus and is receiving desmopressin. Which of the following should the nurse monitor?
- A. Fasting blood glucose
- B. Carbohydrate intake
- C. Hematocrit
- D. Weight
Correct Answer: D
Rationale: The correct answer is D: Weight. Desmopressin can cause fluid retention, so monitoring the client's weight is crucial to detect signs of water intoxication or overhydration, which can occur with the medication. Monitoring fasting blood glucose (choice A) is not directly related to desmopressin use in diabetes insipidus. Carbohydrate intake (choice B) is important for diabetes management but is not specifically relevant to monitoring desmopressin therapy. Hematocrit (choice C) is not typically influenced by desmopressin use in diabetes insipidus.
A nurse on an acute med-surgical unit is performing assessments on a group of clients. Which is the highest priority?
- A. Client with surgical hypoparathyroidism and positive Trousseau's sign
- B. Client with Clostridium difficile and acute diarrhea
- C. Client with acute kidney injury and low urine specific gravity
- D. Client with oral cancer and reports a sore on his gums
Correct Answer: A
Rationale: The correct answer is A. A positive Trousseau's sign indicates hypocalcemia, which can lead to life-threatening complications like tetany or laryngospasm, making it the highest priority. Choices B, C, and D, while important, do not pose immediate life-threatening risks compared to the potential complications of severe hypocalcemia seen in a client with surgical hypoparathyroidism and a positive Trousseau's sign.
A client has a prescription for sertraline to treat depression. Which of the following statements by the client indicates an understanding of the medication treatment plan?
- A. I will start feeling better immediately after starting the medication
- B. I can expect to urinate frequently while on this medication
- C. I understand I may experience difficulty sleeping on this medication
- D. I should decrease my sodium intake while on this medication
Correct Answer: C
Rationale: The correct answer is C. Difficulty sleeping is a common side effect of sertraline, an SSRI used to treat depression. Clients should be educated to expect this, especially during the early stages of treatment. Choice A is incorrect because sertraline may take a few weeks to show its full effect. Choice B is incorrect as increased urination is not a common side effect of sertraline. Choice D is unrelated to the side effects or management of sertraline.
A nurse is observing bonding between the client and her newborn. Which of the following actions by the client requires the nurse to intervene?
- A. Holding the newborn in an en face position
- B. Asking the father to change the newborn's diaper
- C. Requesting the nurse to take the newborn to the nursery so she can rest
- D. Viewing the newborn's actions as uncooperative
Correct Answer: D
Rationale: The correct answer is D because viewing the newborn's actions as uncooperative indicates a negative interaction with the newborn and suggests impaired bonding, which requires intervention. Choices A, B, and C are not indicative of impaired bonding. Holding the newborn in an en face position is a positive way to bond with the baby. Asking the father to change the diaper shows involvement of both parents in caring for the newborn, which is beneficial for bonding. Requesting the nurse to take the newborn to the nursery so the mother can rest is a normal request and does not necessarily indicate impaired bonding.
A nurse is caring for a client recovering from bowel surgery who has a nasogastric (NG) tube connected to low intermittent suction. Which of the following assessment findings should indicate to the nurse that the NG tube may not be functioning properly?
- A. Drainage fluid is greenish-yellow
- B. Aspirate pH of 3
- C. Abdominal rigidity
- D. Air bubbles noted in the NG tube
Correct Answer: C
Rationale: Abdominal rigidity can indicate a serious complication, such as a blockage or infection, requiring immediate intervention to determine if the NG tube is functioning properly. Choices A, B, and D are not indicative of a malfunctioning NG tube. Greenish-yellow drainage fluid may be normal, an aspirate pH of 3 is within the expected range for gastric contents, and air bubbles in the NG tube are not abnormal as long as they are moving.