Nokea
Four clients present to the emergency department. The nurse should plan to see which of the following clients first?
- A. A 6-year-old client with a dislocated left shoulder
- B. A 26-year-old client with sickle cell disease and severe joint pain
- C. A 76-year-old client who is confused, febrile, and has foul-smelling urine
- D. A 50-year-old client with slurred speech, disorientation, and headache
Correct Answer: D
Rationale: The correct answer is D. A client presenting with symptoms of a stroke, such as slurred speech, disorientation, and headache, requires immediate attention due to the possibility of a neurological emergency. Choices A, B, and C, although concerning, do not present with symptoms as urgent as those of a potential stroke. Dislocated shoulder, sickle cell disease with joint pain, and confusion with febrile illness can be addressed after ensuring the client with stroke-like symptoms receives prompt evaluation and intervention.
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What is the priority nursing intervention for a patient experiencing an acute asthma attack?
- A. Administer bronchodilators
- B. Monitor oxygen saturation
- C. Provide supplemental oxygen
- D. Start IV fluids
Correct Answer: A
Rationale: The correct answer is to administer bronchodilators. In an acute asthma attack, the priority is to open the airways and improve airflow. Bronchodilators like albuterol are crucial in providing immediate relief to the patient. Monitoring oxygen saturation (choice B) is important but administering bronchodilators takes precedence in managing the acute attack. Providing supplemental oxygen (choice C) may be necessary but addressing the airway obstruction with bronchodilators is the priority. Starting IV fluids (choice D) is not the priority in an acute asthma attack unless specifically indicated for other reasons such as dehydration.
A healthcare provider is reviewing the laboratory data of a client who is receiving total parenteral nutrition. Which of the following findings should the healthcare provider report?
- A. Serum calcium 8.5 mg/dL
- B. Blood glucose level 120 mg/dL
- C. Serum sodium 138 mEq/L
- D. Serum albumin 3.5 g/dL
Correct Answer: D
Rationale: The correct answer is D: Serum albumin 3.5 g/dL. A low serum albumin level indicates protein deficiency, which can be a complication of TPN therapy and requires prompt intervention. The other laboratory findings provided (serum calcium 8.5 mg/dL, blood glucose level 120 mg/dL, and serum sodium 138 mEq/L) are within normal ranges and do not specifically indicate complications related to TPN therapy.
A client has a prescription for digoxin. Which of the following instructions should the nurse include?
- A. Take this medication with food.
- B. Avoid taking antacids at the same time as this medication.
- C. Take this medication if your heart rate is above 100/min.
- D. Notify your provider if you experience nausea or visual changes.
Correct Answer: D
Rationale: The correct instruction the nurse should include for a client prescribed digoxin is to notify the provider if they experience nausea or visual changes, as these symptoms can indicate digoxin toxicity. Option A is incorrect because digoxin should be taken on an empty stomach for better absorption. Option B is incorrect as antacids can interfere with the absorption of digoxin. Option C is incorrect as taking digoxin based on heart rate alone is not appropriate.
A client at risk for osteoporosis is being taught by a nurse about dietary measures to increase calcium intake. Which of the following foods should the nurse recommend?
- A. Carrots
- B. Cottage cheese
- C. Bananas
- D. Broccoli
Correct Answer: D
Rationale: The correct answer is D: Broccoli. Broccoli is high in calcium, making it a suitable recommendation for clients at risk for osteoporosis. Carrots, Cottage cheese, and Bananas are not significant sources of calcium compared to broccoli, and therefore, they are not the best choices to increase calcium intake.
A nurse is planning care for a client who is postoperative following abdominal surgery. Which of the following interventions should the nurse implement to prevent respiratory complications?
- A. Encourage the client to ambulate twice daily.
- B. Encourage the client to deep breathe and cough every hour.
- C. Encourage the client to use an incentive spirometer every hour.
- D. Instruct the client to avoid coughing to prevent pain.
Correct Answer: C
Rationale: The correct answer is C. Encouraging the client to use an incentive spirometer every hour is crucial to prevent respiratory complications postoperatively. Incentive spirometry helps in lung expansion and prevents atelectasis, which is common after abdominal surgery. Choice A, encouraging ambulation, is important for preventing complications but does not directly address respiratory issues. Choice B, deep breathing and coughing every hour, is also beneficial but not as effective in preventing atelectasis as using an incentive spirometer. Choice D, instructing the client to avoid coughing, is incorrect as coughing helps clear secretions and prevent respiratory complications.