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A patient is admitted to the hospital with symptoms consistent with a right hemisphere stroke. Which neurovascular assessment requires immediate intervention by the nurse?
- A. Pupillary changes to ipsilateral dilation.
- B. Left-sided facial drooping and dysphagia.
- C. Orientation to person and place only.
- D. Unequal bilateral hand grip strengths.
Correct Answer: A
Rationale: Pupillary changes to ipsilateral dilation indicate increased intracranial pressure, which is a life-threatening complication of stroke. The nurse should notify the physician and prepare for emergency measures.
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A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA), which information should the nurse include in the discharge instructions?
- A. Use incentive spirometer.
- B. Monitor urinary stream for decrease in output.
- C. Report when hematuria becomes pink tinged.
- D. Restrict physical activities.
Correct Answer: B
Rationale: Monitoring urinary stream for decrease in output is critical to detect urinary retention or obstruction, potential complications of TUNA.
The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?
- A. Redness and edema noted at the incision site.
- B. Apical heart rate of 100 to 110 beats/minute.
- C. High-pitched sound heard upon inspiration.
- D. Pain rating of 8 on a scale of 0 to 10.
Correct Answer: C
Rationale: High-pitched sound heard upon inspiration is a sign of stridor, which is a life-threatening emergency that indicates airway obstruction. The nurse should call for help, administer oxygen, and prepare for intubation or tracheostomy.
Following a motor vehicle accident, a client with chest trauma receives a chest tube to relieve a hemothorax. Two hours following the chest tube insertion, the nurse observes the water level in the water-seal chamber is rising during inspiration and falling during expiration. Which action should the nurse implement?
- A. Lift and clear drainage from the chest tube.
- B. Inspect the tube insertion site for leaking.
- C. Continue to monitor the drainage system.
- D. Auscultate lungs for unequal breath sounds.
Correct Answer: C
Rationale: Continuing to monitor the drainage system is the best action for the nurse to implement, as the water level fluctuations are normal and expected in a water-seal drainage system. The water level should rise during inspiration and fall during expiration, reflecting the changes in intrathoracic pressure.
A client with acute renal injury (AKI) weighs 110.3 pounds (50 kg) and has a potassium level of 6.7 mEq/L (6.7 mmol/L) is admitted to the hospital. Which prescribed medication should the nurse administer first?
- A. Sodium polystyrene sulfonate 15 grams by mouth.
- B. Sevelamer one tablet by mouth.
- C. Calcium acetate one tablet by mouth.
- D. Epoetin alfa, recombinant 2,500 units subcutaneously.
Correct Answer: A
Rationale: Sodium polystyrene sulfonate is a medication that binds to excess potassium in the gastrointestinal tract and removes it from the body through feces. It is used to treat hyperkalemia, which is a high level of potassium in the blood. Hyperkalemia can cause cardiac arrhythmias and muscle weakness, and it is a common complication of AKI. Therefore, this medication should be administered first to lower the potassium level and prevent life-threatening complications.
Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?
- A. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus.
- B. Isolate the client from other clients, family, and healthcare workers not wearing proper PPE.
- C. Report the COVID-19 result to the local health department according to CDC guidelines.
- D. Explain to the client to inform others that they may have been potentially exposed in the last 14 days.
Correct Answer: B
Rationale: Isolating the client from others not wearing proper PPE is the most important action to prevent transmission of COVID-19, given the client's symptoms suggestive of the virus.