Nokea
In planning the turning schedule for a bedfast client, it is most important for the nurse to consider what assessment finding?
- A. 4+ pitting edema of both lower extremities.
- B. A Braden risk assessment scale rating score of ten.
- C. Warm, dry skin with a fever of 100‚° F.
- D. Hypoactive bowel sounds with infrequent bowel movements.
Correct Answer: B
Rationale: The correct answer is B: A Braden risk assessment scale rating score of ten. This is crucial because the Braden scale assesses the client's risk for developing pressure ulcers. A score of ten indicates a very high risk, requiring frequent repositioning to prevent pressure ulcers.
Choice A is incorrect because 4+ pitting edema of both lower extremities indicates fluid overload, not directly related to turning schedule planning.
Choice C is incorrect because warm, dry skin with a fever of 100‚° F suggests a possible infection, but does not affect the need for turning schedule planning.
Choice D is incorrect as hypoactive bowel sounds and infrequent bowel movements are related to gastrointestinal function, not directly impacting the turning schedule.
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A client receiving total parenteral nutrition (TPN) through a central line suddenly develops dyspnea, chest pain, and a drop in blood pressure. What should the nurse do first?
- A. Stop the TPN infusion.
- B. Notify the healthcare provider.
- C. Place the client in Trendelenburg position.
- D. Administer oxygen at 2 liters/minute.
Correct Answer: C
Rationale: The correct answer is C: Place the client in Trendelenburg position. This is the first action to take in a client with suspected air embolism, a potential complication of central line insertion. Placing the client in Trendelenburg position with the head down and the legs elevated can help prevent air from reaching the heart and lungs. This action can help stabilize the client's condition before further interventions can be implemented.
Stopping the TPN infusion (choice A) can be important, but the priority in this situation is to address the potential air embolism. Notifying the healthcare provider (choice B) can be done after the immediate intervention. Administering oxygen (choice D) is important, but placing the client in Trendelenburg position takes precedence in this emergency situation.
The client has just been diagnosed with Addison's disease. Which clinical manifestation should the nurse expect to find?
- A. Hypertension and hyperglycemia.
- B. Hyperpigmentation and hypotension.
- C. Exophthalmos and tachycardia.
- D. Weight gain and fluid retention.
Correct Answer: B
Rationale: The correct answer is B: Hyperpigmentation and hypotension. Addison's disease is characterized by adrenal insufficiency, leading to low cortisol and aldosterone levels. Hyperpigmentation occurs due to elevated levels of ACTH, causing melanin deposition. Hypotension results from aldosterone deficiency, leading to sodium and water loss. Choice A is incorrect because Addison's disease does not typically present with hypertension or hyperglycemia. Choice C is incorrect as exophthalmos and tachycardia are not typically associated with Addison's disease. Choice D is incorrect as weight gain and fluid retention are not common manifestations of Addison's disease.
A client with schizophrenia is prescribed haloperidol (Haldol). The nurse should monitor the client for which potential side effect?
- A. Tardive dyskinesia.
- B. Orthostatic hypotension.
- C. Photosensitivity.
- D. Hyperglycemia.
Correct Answer: A
Rationale: The correct answer is A: Tardive dyskinesia. Haloperidol is a first-generation antipsychotic known to cause extrapyramidal side effects, including tardive dyskinesia, which is characterized by involuntary repetitive movements of the face and body. This side effect is a serious concern due to its potential to be irreversible. Monitoring for tardive dyskinesia is crucial in clients taking haloperidol to detect and manage symptoms promptly.
Explanation for incorrect choices:
B: Orthostatic hypotension - This side effect is more commonly associated with other antipsychotic medications, particularly second-generation ones.
C: Photosensitivity - Haloperidol does not typically cause photosensitivity as a side effect.
D: Hyperglycemia - While some antipsychotic medications may lead to metabolic side effects like hyperglycemia, haloperidol is not typically associated with this specific side effect.
A client is undergoing chemotherapy and is at risk for developing thrombocytopenia. What precaution should the nurse teach the client to minimize the risk of bleeding?
- A. Use a soft-bristled toothbrush.
- B. Engage in daily aerobic exercise.
- C. Take aspirin for headaches.
- D. Use an electric razor for shaving.
Correct Answer: A
Rationale: The correct answer is A: Use a soft-bristled toothbrush. Chemotherapy can cause low platelet levels, increasing the risk of bleeding. Using a soft-bristled toothbrush can help prevent gum bleeding and trauma to the gums, reducing the risk of bleeding. Engaging in daily aerobic exercise (B) can increase the risk of injury and bleeding for a client with thrombocytopenia. Taking aspirin (C) can further decrease platelet function and increase bleeding risk. Using an electric razor (D) is recommended to prevent skin cuts and bleeding due to the fragile skin associated with chemotherapy-induced thrombocytopenia.
The client has acute kidney injury (AKI). Which assessment finding requires immediate intervention?
- A. Urine output of 50 ml in the last hour.
- B. Serum potassium of 6.2 mEq/L.
- C. Blood pressure of 150/90 mm Hg.
- D. Serum creatinine of 2.5 mg/dL.
Correct Answer: B
Rationale: The correct answer is B: Serum potassium of 6.2 mEq/L. Hyperkalemia is a life-threatening condition in AKI. High potassium levels can lead to cardiac arrhythmias and must be addressed immediately. Choice A is concerning but not as critical as hyperkalemia. Choice C, elevated blood pressure, needs monitoring but does not require immediate intervention. Choice D, elevated serum creatinine, indicates kidney dysfunction but does not pose an immediate threat compared to hyperkalemia.