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An adult male who lives alone is brought to the Emergency Department by his daughter. He is unresponsive, with minimal respiratory effort, and his pupils are fixed and dilated. At the daughter's request, the client is intubated and mechanically ventilated. Which nursing intervention has the highest priority?
- A. Offer to 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. Explore the possibility of organ donation with the family.
Correct Answer: B
Rationale: The highest priority nursing intervention in this scenario is to determine if the client has an executed living will. A living will provides guidance on the client's preferences for medical care in situations where they cannot communicate. This information is crucial in guiding the care team on how to proceed with treatment. Options A, C, and D, though important in certain circumstances, are not the highest priority in this situation where immediate decisions regarding the client's care need to be made.
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The healthcare provider is assessing a client with left-sided heart failure. Which laboratory value should be monitored closely?
- A. Serum sodium of 135 mEq/L
- B. Serum potassium of 4.5 mEq/L
- C. Serum creatinine of 1.8 mg/dl
- D. Serum glucose of 200 mg/dl
Correct Answer: C
Rationale: In a client with left-sided heart failure, monitoring serum creatinine is crucial to evaluate kidney function and fluid balance. Elevated creatinine levels can indicate impaired kidney function, which is common in heart failure due to decreased cardiac output and renal perfusion. Serum sodium levels (choice A) are important but are more closely associated with fluid balance and heart failure exacerbation. Serum potassium (choice B) is also important to monitor, but it is more closely linked to cardiac arrhythmias rather than kidney function. Serum glucose levels (choice D) are significant but are not the priority for monitoring in left-sided heart failure.
A client with liver cirrhosis and ascites is admitted with jaundice. Which laboratory value is most concerning to the nurse?
- A. Serum albumin of 3.0 g/dl
- B. Bilirubin of 3.0 mg/dl
- C. Ammonia level of 80 mcg/dl
- D. Prothrombin time of 18 seconds
Correct Answer: C
Rationale: An ammonia level of 80 mcg/dl is elevated and concerning in a client with liver cirrhosis, as it may indicate hepatic encephalopathy. Elevated ammonia levels can lead to neurological symptoms such as confusion, altered mental status, and even coma. Serum albumin, bilirubin, and prothrombin time are important in liver cirrhosis but are not the most concerning for acute neurological deterioration associated with hepatic encephalopathy.
A male client with cancer who has lost 10 pounds during the last months tells the nurse that beef, chicken, and eggs, which used to be his favorite foods, now taste 'bitter'. He complains that he simply has no appetite. What action should the nurse implement?
- A. Suggest the use of alternative sources of protein such as dairy products and nuts.
- B. Encourage the client to eat smaller, more frequent meals.
- C. Offer nutritional supplements between meals.
- D. Discuss the possibility of appetite stimulants with the healthcare provider.
Correct Answer: A
Rationale: Offering alternative protein sources like dairy products and nuts can help maintain nutrition when the client finds certain foods unpalatable, as in this case where beef, chicken, and eggs taste 'bitter'. Encouraging smaller, more frequent meals may not address the issue of unpalatable foods. Offering nutritional supplements between meals may not specifically address the problem of protein intake. Discussing appetite stimulants should be considered after exploring less invasive options first.
To reduce staff nurse role ambiguity, which strategy should the nurse-manager implement?
- A. Review the staff nurse job description to ensure that it is clear, accurate, and current.
- B. Conduct regular meetings to clarify roles.
- C. Increase communication between team members.
- D. Provide additional training for new nurses.
Correct Answer: A
Rationale: The correct answer is A: Review the staff nurse job description to ensure that it is clear, accurate, and current. By ensuring that job descriptions are clear and up-to-date, nurse-managers can reduce ambiguity and confusion about roles and responsibilities. Choice B, conducting regular meetings to clarify roles, may help but may not address the root cause of ambiguity. Choice C, increasing communication between team members, is important but may not specifically target role ambiguity. Choice D, providing additional training for new nurses, is valuable but may not directly address role ambiguity among existing staff.
A female client with type 2 diabetes reports that she has been taking her medications as prescribed but her blood glucose levels remain elevated. Which action should the nurse take first?
- A. Check the client's current blood glucose level.
- B. Assess the client's diet and medication adherence.
- C. Review the client's medication list for potential interactions.
- D. Obtain a hemoglobin A1c level.
Correct Answer: C
Rationale: The correct action the nurse should take first is to review the client's medication list for potential interactions. This step is crucial as it can help identify any medications that might be contributing to the elevated blood glucose levels. Checking the current blood glucose level (choice A) is important but not the first action to address the ongoing issue. Assessing the client's diet and medication adherence (choice B) is also important, but reviewing the medication list should be the initial step to rule out any drug-related causes. Obtaining a hemoglobin A1c level (choice D) is a valuable assessment but may not address the immediate need to identify potential medication interactions.