Nokea
An adult male who lives alone is brought to the Emergency Department by his daughter who found him unresponsive. Initial assessment indicated that the client has minimal respiratory effort, and his pupils are fixed and dilated. At the daughter's request, the client is intubated and ventilated. Which nursing intervention has the highest priority?
- A. Notify the client's minister of his condition.
- B. Determine if the client has an executed living will.
- C. Provide the family with information about palliative care.
- D. Discuss the possibility of organ donation with the family.
Correct Answer: B
Rationale: Verifying whether the client has an executed living will is crucial to ensuring that his treatment preferences are followed. In this critical situation, knowing the client's wishes regarding medical interventions is paramount. Options A, C, and D are not the highest priority as they do not directly address the immediate need to determine the client's treatment preferences.
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When finding a client sitting on the floor, the nurse calls for help from the unlicensed assistive personnel (UAP). Which task should the nurse ask the UAP to do?
- A. Check for any abrasions or bruises.
- B. Help the client to stand.
- C. Get a blood pressure cuff.
- D. Report the fall to the nurse-manager.
Correct Answer: C
Rationale: The correct task for the nurse to ask the unlicensed assistive personnel (UAP) to do in this situation is to "Get a blood pressure cuff." This is important because assessing the client's vital signs, including blood pressure, is crucial after a fall to ensure there are no underlying issues like hypotension. Choices A and B may be important tasks for the nurse to perform as part of the assessment and care of the client. However, in this scenario, the immediate concern should be to check the client's blood pressure. Choice D is not the most urgent task at this time, as assessing the client's condition takes precedence.
The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client's plan of care?
- A. Record urine output every hour
- B. Monitor blood pressure frequently
- C. Evaluate neurological status
- D. Maintain seizure precautions
Correct Answer: B
Rationale: Monitoring blood pressure frequently is the highest priority intervention for a client diagnosed with pheochromocytoma. This rare tumor can lead to life-threatening hypertension due to catecholamine secretion. Evaluating neurological status and maintaining seizure precautions are important but are not the highest priority in this case. Recording urine output, though essential for overall assessment, is not the priority compared to monitoring blood pressure in a client with pheochromocytoma.
A client with urticaria due to environmental allergies is taking diphenhydramine (Benadryl). Which complaint should the nurse identify as a side effect of this OTC medication?
- A. Nausea and indigestion.
- B. Hypersalivation.
- C. Eyelid and facial twitching.
- D. Increased appetite.
Correct Answer: A
Rationale: The correct answer is A: Nausea and indigestion. Diphenhydramine, an antihistamine, commonly causes gastrointestinal side effects such as nausea and indigestion. These symptoms are often reported by individuals taking this medication. Choices B, C, and D are incorrect because hypersalivation, eyelid and facial twitching, and increased appetite are not typically associated with diphenhydramine use.
The nurse is caring for a client with a history of atrial fibrillation who is prescribed warfarin (Coumadin). Which laboratory value should the nurse monitor closely?
- A. Prothrombin time (PT)
- B. Hemoglobin level
- C. International Normalized Ratio (INR)
- D. Serum sodium level
Correct Answer: C
Rationale: The INR should be closely monitored in a client prescribed warfarin (Coumadin) to assess the effectiveness and safety of anticoagulation therapy. Monitoring the INR helps determine if the client's blood is clotting appropriately. While prothrombin time (PT) is related to warfarin therapy, the INR is a more precise measure. Hemoglobin level and serum sodium level are not directly related to monitoring warfarin therapy.
The nurse weighs a 6-month-old infant during a well-baby check-up and determines that the baby's weight has tripled compared to the birth weight of 7 pounds 8 ounces. The mother asks if the baby is gaining enough weight. What response should the nurse offer?
- A. Your baby is gaining weight right on schedule
- B. What food does your baby usually eat in a normal day?
- C. The baby is below the normal percentile for weight gain
- D. What was the baby's weight at the last well-baby check-up?
Correct Answer: A
Rationale: The correct answer is A: 'Your baby is gaining weight right on schedule.' Tripling of birth weight by 6 months is a normal growth pattern in infants, indicating appropriate weight gain and development. Choice B is unrelated to the question as it focuses on the baby's diet rather than addressing the weight gain concern. Choice C is incorrect as tripling the birth weight is considered a healthy growth pattern, not below normal percentile. Choice D is irrelevant to the mother's question about the adequacy of weight gain.