Nokea
An adult client is admitted with flank pain and is diagnosed with acute pyelonephritis. What is the priority nursing action?
- A. Auscultate for presence of bowel sounds.
- B. Monitor hemoglobin and hematocrit
- C. Encourage turning and deep breathing
- D. Administer IV antibiotics as prescribed.
Correct Answer: D
Rationale: Administering IV antibiotics promptly is critical to treat the infection and prevent complications in acute pyelonephritis.
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Hypoglycemia in an infant is defined as whole blood glucose level less than
- A. 40 mg/dl
- B. 50 mg/dl
- C. 60 mg/dl
- D. 80 mg/dl
Correct Answer: A
Rationale: Hypoglycemia in infants is defined as a whole blood glucose level less than 40 mg/dl, as this threshold is critical for brain function.
The nurse is caring for a school-age child who has had a cardiac catheterization. The child tells the nurse that the bandage is “too wet.†The nurse finds the bandage and bed soaked with blood. What is the priority nursing action?
- A. Notify physician
- B. Apply new bandage with more pressure
- C. Place the child in Trendelenburg position
- D. Apply direct pressure above catheterization site
Correct Answer: D
Rationale: If bleeding occurs, direct continuous pressure is applied 2.5 cm (1 inch) above the percutaneous skin site to localize pressure over the vessel puncture. Notifying a physician and applying a new bandage can be done after pressure is applied. The nurse can have someone else notify the physician while the pressure is being maintained. It is not a helpful intervention to place the girl in the Trendelenburg position. It would increase the drainage from the lower extremities.
A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with diminished bibasilar breath sounds. Vital signs are temperature 101F, heart rate 128 beats/minute, respirations 28 breaths/minute, and blood pressure 122/82. Which intervention is most important for the nurse to implement first?
- A. Obtain oxygen saturation level
- B. Encourage incentive spirometry
- C. Assess lower extremity circulation
- D. Administer PRN oral antipyretic
Correct Answer: D
Rationale: Administering an antipyretic addresses the fever, which is a priority in this client to prevent further complications.
In the treatment of asthma, inhaled corticosteroids:
- A. Relieve acute symptoms
- B. Prevent long-term symptoms
- C. Cause airway constriction
- D. Are contraindicated in pregnancy
Correct Answer: B
Rationale: Inhaled corticosteroids are used in asthma management to prevent inflammation and control long-term symptoms, though they do not relieve acute attacks.
A client admitted to a surgical unit is being evaluated for an intestinal obstruction. The healthcare provider prescribes a nasogastric tube (NGT) to be inserted and placed to intermittent low wall suction. Which intervention should the nurse implement to facilitate proper tube placement?
- A. Soak nasogastric tube in warm water
- B. Insert tube with client's head tilted back
- C. Apply suction while inserting tube
- D. Elevate head of bed 60 to 90 degrees
Correct Answer: D
Rationale: Elevating the head of the bed helps facilitate proper placement of the NGT and reduces the risk of aspiration.