Nokea
An adult male who fell from a roof and fractured his left femur is admitted for surgical stabilization after having a soft cast applied in the emergency department. Which assessment finding warrants immediate intervention by the nurse?
- A. Weak palpable distal pulses
- B. Pain at the fracture site
- C. Mild swelling of the leg
- D. Bruising around the fracture site
Correct Answer: A
Rationale: In a patient with a fractured femur, weak palpable distal pulses can indicate compromised circulation to the lower extremity. This finding suggests a potential vascular compromise that requires immediate intervention to prevent further complications like compartment syndrome or ischemia. Pain at the fracture site, mild swelling of the leg, and bruising around the fracture site are expected following such an injury and surgical stabilization, and while they should be monitored, they do not require immediate intervention like addressing compromised circulation.
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For the past 24 hours, an antidiarrheal agent, diphenoxylate, has been administered to a bedridden, older client with infectious gastroenteritis. Which finding requires the nurse to take further action?
- A. Tented skin turgor
- B. Decreased bowel sounds
- C. Persistent diarrhea
- D. Dehydration
Correct Answer: A
Rationale: The correct answer is A. Tented skin turgor is a sign of dehydration, which can be exacerbated by the use of antidiarrheals in clients with gastroenteritis. In dehydration, the skin loses its elasticity and becomes less resilient when pinched. Therefore, the nurse should take immediate action upon noticing tented skin turgor to prevent further complications. Choices B, C, and D are incorrect because decreased bowel sounds, persistent diarrhea, and dehydration are expected findings in a client with gastroenteritis who has been administered an antidiarrheal agent.
A client with chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Which intervention should the nurse implement first?
- A. Administer oxygen therapy as prescribed.
- B. Elevate the head of the bed.
- C. Obtain a sputum culture.
- D. Administer antibiotics as prescribed.
Correct Answer: A
Rationale: In a client with COPD admitted with pneumonia, the priority intervention should be to administer oxygen therapy as prescribed. This is crucial to improve oxygenation, especially in a client with compromised respiratory function. Elevating the head of the bed can help with breathing but is secondary to ensuring adequate oxygenation. Obtaining a sputum culture and administering antibiotics are important steps in the treatment of pneumonia but come after ensuring adequate oxygen supply.
While taking vital signs, a critically ill male client grabs the nurse's hand and asks the nurse not to leave. What action is best for the nurse to take?
- A. Pull up a chair and sit beside the client's bed.
- B. Reassure the client that you will return shortly.
- C. Ask another nurse to stay with the client.
- D. Continue taking vital signs and then leave the room.
Correct Answer: A
Rationale: The best action for the nurse to take in this situation is to pull up a chair and sit beside the client's bed. By doing so, the nurse can provide emotional support and comfort to the critically ill patient who is feeling vulnerable. Sitting with the client also shows empathy and a willingness to listen to the client's needs. Reassuring the client that the nurse will return shortly (Choice B) may not address the immediate need for emotional support. Asking another nurse to stay with the client (Choice C) may not establish the same level of connection and comfort as sitting with the client personally. Continuing to take vital signs and then leaving the room (Choice D) disregards the client's emotional needs in that moment.
In caring for a client with a PCA infusion of morphine sulfate through the right cephalic vein, the nurse assesses that the client is lethargic with a blood pressure of 90/60, pulse rate of 118 beats per minute, and respiratory rate of 8 breaths per minute. What assessment should the nurse perform next?
- A. Note the appearance and patency of the client's peripheral IV site.
- B. Palpate the volume of the client's right radial pulse.
- C. Auscultate the client's breath sounds bilaterally.
- D. Observe the amount and dose of morphine in the PCA pump syringe.
Correct Answer: D
Rationale: In this scenario, the nurse is dealing with a lethargic client with concerning vital signs after a PCA infusion of morphine sulfate. The next assessment the nurse should perform is to observe the amount and dose of morphine in the PCA pump syringe. This is crucial to evaluate for possible overdose, as the client's symptoms could be indicative of opioid toxicity. Checking the morphine amount and dose will help the nurse adjust the treatment accordingly. Choices A, B, and C do not directly address the potential cause of the client's lethargy and abnormal vital signs related to the morphine infusion.
A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which laboratory value requires immediate intervention?
- A. Serum glucose of 300 mg/dl
- B. Serum potassium of 5.5 mEq/L
- C. Serum bicarbonate of 18 mEq/L
- D. Serum sodium of 135 mEq/L
Correct Answer: C
Rationale: A serum bicarbonate level of 18 mEq/L requires immediate intervention in a client with diabetic ketoacidosis (DKA). A low serum bicarbonate level indicates metabolic acidosis, which can be life-threatening. This condition needs urgent correction to restore acid-base balance. Serum glucose of 300 mg/dl, serum potassium of 5.5 mEq/L, and serum sodium of 135 mEq/L are abnormal values, but they do not pose an immediate threat to the client's life compared to the metabolic acidosis indicated by the low serum bicarbonate level.