Nokea
A priority nursing diagnosis for an adult female who has pruritus and is continuously scratching the affected areas and demonstrates agitation and anxiety regarding the itching sensation would be:
- A. Risk for infection related to pruritus.
- B. Ineffective health maintenance related to lack of knowledge of the disease process.
- C. Unsporced skin integrity related to dehydration from the treatment medications.
- D. Social isolation related to poor self-image.
Correct Answer: A
Rationale: Scratching due to pruritus increases the risk of skin breakdown and infection, making this the priority nursing diagnosis.
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A client post-appendectomy reports shoulder pain on the second postoperative day. The nurse should suspect which complication?
- A. Pneumonia.
- B. Subdiaphragmatic abscess.
- C. Deep vein thrombosis.
- D. Wound infection.
Correct Answer: B
Rationale: Shoulder pain post-appendectomy may indicate a subdiaphragmatic abscess due to referred pain from diaphragmatic irritation. Pneumonia, thrombosis, and wound infection typically present with other symptoms. CN: Physiological adaptation; CL: Analyze
The nurse is planning care for a client being admitted with bleeding esophageal varices. Vital signs are: Pulse 100; respiratory rate 22; and blood pressure 100/58. The nurse should prepare the client for which of the following? Select all that apply.
- A. Administration of intravenous Octreotide (Sandostatin).
- B. Endoscopy.
- C. Administration of a blood product.
- D. Minnesota tube insertion.
- E. Transjugular intrahepatic portosystemic shunt (TIPS).
Correct Answer: A,B,C,D
Rationale: Octreotide (A) reduces portal pressure, endoscopy (B) diagnoses and treats bleeding, blood products (C) correct hypovolemia, and a Minnesota tube (D) controls bleeding. TIPS (E) is a later intervention.
Which intervention should the nurse suggest to help a client with multiple sclerosis avoid episodes of urinary incontinence?
- A. Limit fluid intake to 1,000 mL/day.
- B. Insert an indwelling urinary catheter.
- C. Establish a regular voiding schedule.
- D. Administer prophylactic antibiotics, as ordered.
Correct Answer: C
Rationale: A regular voiding schedule helps manage incontinence by promoting bladder emptying before urgency. Fluid restriction risks dehydration, indwelling catheters increase infection risk, and antibiotics are not preventive for incontinence.
The nurse receives the following critical laboratory results for a client with end-stage renal disease. The nurse anticipates the physician to prescribe which blood product? See the image below.
- A. Packed Red Blood Cells (PRBCs)
- B. Fresh Frozen Plasma (FFP)
- C. Albumin
- D. Platelets
Correct Answer: A
Rationale: End-stage renal disease often leads to anemia due to decreased erythropoietin production, making PRBCs the likely prescribed blood product to correct severe anemia. FFP, albumin, and platelets address other issues not typically primary in this context.
A confused client with carbon monoxide poisoning experiences dizziness when ambulating to the bathroom. The nurse should:
- A. Put all four side rails up on the bed.
- B. Ask the unlicensed personnel to place restraints on the client's upper extremities.
- C. Request that the client's roommate put the call light on when the client is attempting to get out of bed.
- D. Check on the client at regular intervals to ascertain the need to use the bathroom.
Correct Answer: D
Rationale: Regular checks ensure safety and assist with bathroom needs, addressing dizziness and confusion. Side rails and restraints risk injury or agitation. Relying on a roommate is unreliable.