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After receiving a report on an inpatient acute care unit, which client should the nurse assess first?
- A. Client with pneumonia who has a fever of 101.5°F
- B. Client who underwent knee surgery and needs dressing change
- C. Client with a bowel obstruction due to a volvulus experiencing abdominal rigidity
- D. Client with diabetes requesting insulin
Correct Answer: C
Rationale: The correct answer is C. Abdominal rigidity in a client with a bowel obstruction could indicate peritonitis, a serious complication requiring immediate attention. Volvulus, a twisting of the intestine, can lead to bowel ischemia and necrosis. Clients with pneumonia (choice A) may need assessment and treatment for infection, but it is not as immediately life-threatening as a bowel obstruction. A client who underwent knee surgery (choice B) needing a dressing change can typically wait for assessment compared to a potential surgical emergency. Similarly, a client with diabetes requesting insulin (choice D) may require attention to maintain blood glucose levels, but it is not as urgent as a suspected bowel obstruction with possible peritonitis.
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A child is admitted with bacterial meningitis. What assessment finding should the nurse monitor most closely?
- A. Monitor the client's skin for rash and lesions.
- B. Monitor for signs of increased intracranial pressure.
- C. Monitor the client's blood pressure closely.
- D. Monitor for changes in heart rate and rhythm.
Correct Answer: B
Rationale: Correct Answer: B. Signs of increased intracranial pressure, such as changes in consciousness or pupil reactivity, are critical to monitor in children with bacterial meningitis to prevent complications. Monitoring the client's skin for rash and lesions (Choice A) is not the priority in bacterial meningitis. While monitoring blood pressure (Choice C) is important, signs of increased intracranial pressure take precedence. Monitoring for changes in heart rate and rhythm (Choice D) is less specific to the condition and may not indicate worsening neurological status.
During an acute exacerbation of asthma, what is the nurse's first action for a client experiencing this condition?
- A. Administer a bronchodilator as prescribed.
- B. Check the client's oxygen saturation.
- C. Reassure the client and encourage deep breathing.
- D. Provide emotional support to reduce anxiety.
Correct Answer: A
Rationale: The correct first action when managing an acute exacerbation of asthma is to administer a bronchodilator as prescribed. Bronchodilators help open the airways and improve breathing in individuals experiencing an asthma exacerbation. Checking oxygen saturation (Choice B) is important but not the first action. Reassuring the client and encouraging deep breathing (Choice C) can be beneficial but should come after administering the bronchodilator. Providing emotional support to reduce anxiety (Choice D) is important but is not the initial priority in managing an acute exacerbation of asthma.
What is the most important assessment for a nurse to conduct on a child diagnosed with intussusception?
- A. Monitor for signs of infection.
- B. Measure abdominal girth and monitor for pain.
- C. Check for bowel movement and changes in stool.
- D. Assess hydration status and monitor urine output.
Correct Answer: C
Rationale: The correct answer is C: 'Check for bowel movement and changes in stool.' Intussusception can cause obstruction in the bowel, leading to symptoms like abdominal pain, vomiting, and 'currant jelly' stools. Monitoring for changes in bowel movement, especially the passage of 'currant jelly' stools, is crucial for early detection of worsening conditions. Choices A, B, and D are important assessments in pediatric care but are not as specific or crucial as checking for changes in bowel movement in a child diagnosed with intussusception.
A client with Crohn's disease reports diarrhea. What intervention should the nurse implement?
- A. Instruct the client to drink clear fluids and avoid solid foods.
- B. Administer antidiarrheal medication as prescribed.
- C. Encourage a high-fiber diet and regular physical activity.
- D. Restrict fluid intake and monitor electrolytes.
Correct Answer: C
Rationale: The correct intervention for a client with Crohn's disease reporting diarrhea is to encourage a high-fiber diet and regular physical activity. A high-fiber diet helps manage diarrhea in Crohn's disease by adding bulk to the stool and promoting more regular bowel movements. Instructing the client to drink clear fluids and avoid solid foods (Choice A) may not be appropriate as it can further exacerbate diarrhea. Administering antidiarrheal medication (Choice B) without addressing the underlying cause may not be the best initial approach. Encouraging a high-fiber diet and physical activity (Choice C) is beneficial for managing symptoms. Restricting fluid intake and monitoring electrolytes (Choice D) is not recommended as it can lead to dehydration, which is a concern in clients with diarrhea.
A client receiving continuous ambulatory peritoneal dialysis (CAPD) has lost weight and exhibits increasing edema. What should the nurse prioritize?
- A. Evaluate the patency of the arteriovenous (AV) graft.
- B. Instruct the client to continue a fluid-restricted diet.
- C. Recommend support stockings for venous return.
- D. Monitor the client's serum albumin levels.
Correct Answer: A
Rationale: In a client receiving continuous ambulatory peritoneal dialysis (CAPD) who has lost weight and exhibits increasing edema, the nurse should prioritize evaluating the patency of the arteriovenous (AV) graft. This assessment is crucial to determine if hemodialysis can be resumed, addressing the client's presenting issues effectively. Instructing the client to continue a fluid-restricted diet (choice B) may not address the underlying issue related to the CAPD. Recommending support stockings for venous return (choice C) is not directly relevant to the situation described. Monitoring the client's serum albumin levels (choice D) may be important but does not directly address the immediate concern of weight loss and increasing edema in a CAPD client.