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Before a dressing change to his legs, which intervention is most important for the nurse to implement?
- A. Encourage the patient to stay at the bedside
- B. Use distraction techniques to reduce pain
- C. Maintain strict aseptic technique
- D. Place a drape over the burn area
Correct Answer: C
Rationale: Maintaining strict aseptic technique is crucial before a dressing change for burn patients to prevent infection. Encouraging the patient to stay at the bedside, using distraction techniques, or placing a drape over the burn area are not as critical as ensuring asepsis in this situation.
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A client with acute pancreatitis is admitted with severe abdominal pain. Which assessment finding should be reported to the healthcare provider immediately?
- A. Decreased bowel sounds
- B. Increased heart rate
- C. Decreased urine output
- D. Elevated blood glucose level
Correct Answer: C
Rationale: Decreased urine output is concerning in a client with acute pancreatitis as it may indicate hypovolemia or renal impairment. In acute pancreatitis, decreased urine output can signify inadequate perfusion to the kidneys, leading to renal failure. While the other options are important to monitor in a client with acute pancreatitis, decreased urine output requires immediate attention to prevent further complications.
The nurse who is working on a surgical unit receives a change of shift report on a group of clients for the upcoming shift. A client with which condition requires the most immediate attention by the nurse?
- A. Gunshot wound three hours ago with dark drainage of 2 cm noted on the dressing.
- B. Mastectomy 2 days ago with 50 ml bloody drainage noted in the Jackson-Pratt drain.
- C. Collapsed lung after a fall 8 hours ago with 100 ml blood in the chest tube collection container
- D. Abdominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills.
Correct Answer: D
Rationale: The correct answer is D. A client who had an abdominal-perineal resection 2 days ago with no drainage on the dressing but is presenting with fever and chills requires immediate attention. This presentation raises concerns for peritonitis, a serious complication that necessitates prompt assessment and intervention to prevent further complications. Choices A, B, and C do not indicate an immediate risk for a life-threatening condition like peritonitis, making them lower priority compared to choice D.
A client is admitted for cellulitis surrounding an insect bite on the lower right arm, and intravenous (IV) antibiotic therapy is prescribed. Which action should the nurse implement before performing venipuncture?
- A. Lower the right arm below the level of the heart.
- B. Elevate the right arm on a pillow.
- C. Apply a tourniquet above the insertion site.
- D. Apply a warm compress to the insertion site.
Correct Answer: A
Rationale: Before performing venipuncture for IV therapy, the nurse should lower the right arm below the level of the heart. Lowering the arm helps dilate the veins, making it easier to locate and access a suitable vein for the procedure. Elevating the arm on a pillow, applying a tourniquet above the insertion site, or applying a warm compress to the insertion site are not appropriate actions before venipuncture as they can affect the venous blood flow and make the procedure more challenging.
A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which intervention is most important?
- A. Administer intravenous fluids as prescribed.
- B. Monitor the client's urine output.
- C. Administer insulin as prescribed.
- D. Administer 50% dextrose IV push.
Correct Answer: C
Rationale: Administering insulin is the most important intervention in managing diabetic ketoacidosis. In DKA, there is a lack of insulin leading to hyperglycemia and ketosis. Insulin administration helps to reduce blood glucose levels and correct metabolic acidosis, which are crucial in treating DKA. Administering intravenous fluids helps with dehydration, monitoring urine output is important to assess renal function, but the priority is addressing the underlying cause of DKA by administering insulin. Administering 50% dextrose IV push is incorrect as it would further elevate blood glucose levels, which is contraindicated in DKA.
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which intervention should the nurse implement first?
- A. Administer a bronchodilator as prescribed.
- B. Assess the client's respiratory rate.
- C. Assess the client's oxygen saturation.
- D. Elevate the head of the bed.
Correct Answer: C
Rationale: Assessing the client's oxygen saturation is crucial in a client with COPD receiving supplemental oxygen to ensure adequate oxygenation. This assessment helps determine if the current oxygen therapy is effective or if adjustments are necessary. While administering a bronchodilator is important in managing COPD, assessing oxygen saturation takes precedence to address the client's immediate oxygen needs. Assessing the respiratory rate is also important but evaluating oxygen saturation provides more direct information about the client's oxygen status. Elevating the head of the bed can improve ventilation but is not the priority when assessing oxygen saturation in a client with COPD receiving supplemental oxygen.