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In the critical care unit, which client should receive the most care hours by a registered nurse (RN)?
- A. A client with a newly inserted Foley catheter and Alzheimer's disease
- B. A 55-year-old with chronic kidney disease
- C. An 82-year-old client with a newly fractured femur and soft wrist restraints
- D. A 72-year-old with pneumonia and sepsis on antibiotics
Correct Answer: C
Rationale: The client with a newly fractured femur and soft wrist restraints should receive the most care hours as they have physical limitations due to the fracture and mental limitations due to being restrained. This client requires continuous monitoring, support, and frequent assessments to prevent complications. Choices A, B, and D do not have the same level of physical and mental care needs as the client with the newly fractured femur and soft wrist restraints.
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During a thyroid storm, what is the nurse's priority intervention for a client experiencing increased heart rate and tremors?
- A. Administer antithyroid medications as prescribed.
- B. Administer a beta-blocker to control the heart rate.
- C. Monitor the client's temperature closely.
- D. Prepare the client for an emergency thyroidectomy.
Correct Answer: A
Rationale: The correct answer is to administer antithyroid medications as prescribed during a thyroid storm. Antithyroid medications help control the overproduction of thyroid hormones, which is crucial in managing symptoms such as increased heart rate and tremors. These symptoms can be life-threatening if not promptly addressed. Administering a beta-blocker (Choice B) may help control the heart rate, but addressing the underlying cause with antithyroid medications is the priority. Monitoring the client's temperature (Choice C) is important but not the priority intervention during a thyroid storm. Lastly, preparing the client for an emergency thyroidectomy (Choice D) is not the initial intervention for managing symptoms of a thyroid storm.
Which medication should the nurse withhold if the client's serum potassium level is 6.2 mEq/L?
- A. Losartan
- B. Spironolactone
- C. Metoprolol
- D. Furosemide
Correct Answer: B
Rationale: The correct answer is B: Spironolactone. Spironolactone is a potassium-sparing diuretic that can lead to hyperkalemia. With potassium levels already elevated at 6.2 mEq/L, withholding Spironolactone is essential to prevent further increase in potassium levels, which could result in dangerous cardiac arrhythmias. Losartan (Choice A) is an angiotensin receptor blocker and does not directly affect potassium levels. Metoprolol (Choice C) is a beta-blocker and also does not impact potassium levels significantly. Furosemide (Choice D) is a loop diuretic that can actually lower potassium levels, so it would not be the medication to withhold in this case.
Which strategy should the nurse implement when teaching a client with low literacy about a new diagnosis of hypertension?
- A. Provide a detailed handout with complex terms
- B. Use simple language and visual aids
- C. Encourage the client to research the diagnosis online
- D. Incorporate medical jargon to explain the condition
Correct Answer: B
Rationale: The correct strategy for teaching a client with low literacy about a new diagnosis of hypertension is to use simple language and visual aids. This approach helps ensure better understanding of the diagnosis and treatment plan by making the information clear and accessible. Providing a detailed handout with complex terms (Choice A) would not be suitable as it may confuse the client further. Encouraging the client to research the diagnosis online (Choice C) could lead to misinformation and overwhelm the client with information they may not understand. Incorporating medical jargon to explain the condition (Choice D) would not be helpful for a client with low literacy as it may complicate rather than clarify the information.
A client with lung cancer is admitted to palliative care. What is the nurse's priority assessment?
- A. Monitor respiratory status and oxygenation.
- B. Evaluate the client's mental status and cognition.
- C. Check the client's pain level and provide comfort.
- D. Assess the client's nutritional status and appetite.
Correct Answer: A
Rationale: Correct Answer: Monitoring respiratory status and oxygenation is crucial in clients with lung cancer, as metastasis to the lungs or pleural effusion can compromise breathing. This assessment helps in early identification of respiratory distress and the need for interventions to maintain adequate oxygenation. Choice B is important but not the priority in this situation. Evaluating mental status and cognition should follow after ensuring the client's physiological needs are met. Choice C, checking pain level and providing comfort, is essential but secondary to assessing respiratory status. Choice D, assessing nutritional status and appetite, is also important but not the priority when the client's breathing is at risk.
A client is diagnosed with tuberculosis and is placed on isoniazid (INH) and rifampin (Rifadin). The nurse should emphasize the importance of
- A. Daily use of a bronchodilator
- B. The importance of taking medication as prescribed
- C. Decreasing salt intake
- D. Avoidance of direct sunlight
Correct Answer: B
Rationale: The correct answer is B: The importance of taking medication as prescribed. In the treatment of tuberculosis, adherence to the prescribed medication regimen is crucial to effectively manage the infection and prevent the development of drug resistance. Choices A, C, and D are incorrect because bronchodilators, salt intake, and sunlight exposure are not directly related to the treatment of tuberculosis with isoniazid and rifampin.