Nokea
Nurses caring for four clients. Which of the following client data should the nurse report to the provider?
- A. A client who has pleurisy and reports pain of 6 on a scale of 0 to 10 when coughing
- B. Client drained a total of 110 mL of serosanguineous fluid from the Jackson Pratt drain within the first 24 hours following surgery
- C. Client who is 4 hours postoperative and has a heart rate of 98 per minute
- D. The client has a prescription for chemotherapy and an absolute neutrophil count of 75/mm3
Correct Answer: D
Rationale: The correct answer is D. The client with chemotherapy and a low neutrophil count is at risk for infection and requires prompt intervention. Reporting this information to the provider is crucial to ensure appropriate monitoring and management to prevent potential complications. Choices A, B, and C do not indicate an immediate risk that requires immediate provider notification. A client reporting pain with pleurisy, a client draining fluid post-surgery, or a client with a heart rate of 98 per minute postoperative are not urgent enough to warrant immediate reporting compared to the client at risk for infection.
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What is the priority nursing action for a patient experiencing an acute asthma attack?
- A. Administer bronchodilators
- B. Administer corticosteroids
- C. Provide supplemental oxygen
- D. Start IV fluids
Correct Answer: A
Rationale: The correct answer is to administer bronchodilators as the priority nursing action for a patient experiencing an acute asthma attack. Bronchodilators help open the airways and improve airflow, which is crucial in managing the acute respiratory distress in asthma. Corticosteroids may be used subsequently to reduce inflammation, but in the acute phase, bronchodilators take precedence. Providing supplemental oxygen is important but may not address the underlying bronchoconstriction characteristic of an asthma attack. Starting IV fluids is not a priority in managing an acute asthma attack unless indicated for specific reasons such as dehydration.
A client with chronic kidney disease is being educated by a nurse about dietary modifications. Which of the following client statements indicates an understanding of the teaching?
- A. I will increase my intake of potassium-rich foods.
- B. I will limit my protein intake to prevent further kidney damage.
- C. I will avoid consuming foods high in phosphorus.
- D. I will increase my intake of dairy products to support kidney function.
Correct Answer: B
Rationale: The correct answer is B. Limiting protein intake is crucial for clients with chronic kidney disease as it helps prevent further kidney damage. Increasing intake of potassium-rich foods (choice A) is not recommended for clients with kidney disease as high potassium levels can be harmful. Avoiding foods high in phosphorus (choice C) is important, but limiting protein intake is a higher priority. Increasing dairy product intake (choice D) is not ideal for clients with kidney disease as they may need to monitor their phosphorus intake from such foods.
What is the most important assessment for a patient with suspected pneumonia?
- A. Monitor lung sounds
- B. Check oxygen saturation
- C. Assess for cough
- D. Assess for fever
Correct Answer: A
Rationale: The most important assessment for a patient with suspected pneumonia is to monitor lung sounds. Lung sounds provide crucial information about the severity of pneumonia, such as crackles or decreased air entry. This assessment helps in evaluating the effectiveness of ventilation and oxygenation. While checking oxygen saturation is important, monitoring lung sounds gives more direct information about the lung involvement in pneumonia. Assessing for cough and fever are also relevant but do not provide as direct and critical information as monitoring lung sounds in the context of suspected pneumonia.
A nurse is providing teaching to a client who is at 28 weeks of gestation and is scheduled for a glucose tolerance test. Which of the following instructions should the nurse include?
- A. You should avoid consuming any food or drink for 8 hours before the test.
- B. You should drink 8 oz of water 1 hour before the test.
- C. You should take an antacid before the test.
- D. You should drink a glass of milk 1 hour before the test.
Correct Answer: A
Rationale: Clients should avoid consuming any food or drink for 8 hours before the glucose tolerance test to ensure accurate results. Choice A is the correct instruction for the client preparing for a glucose tolerance test. Drinking water, taking an antacid, or consuming milk before the test can interfere with the accuracy of the results. Water or any other substance might affect the concentration of glucose in the blood, leading to inaccurate test results. Antacids and milk can also interfere with the test outcome. Therefore, the client should follow the instruction to fast for 8 hours before the test.
A client who is at 30 weeks of gestation and is scheduled for a nonstress test is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should avoid drinking fluids during the test.
- B. I will need to drink a sugar solution before the test.
- C. This test will monitor how my baby is responding to contractions.
- D. This test will assess for fetal lung maturity.
Correct Answer: B
Rationale: The correct answer is B because the client should drink a sugar solution for a glucose challenge test, which is part of the nonstress test protocol during pregnancy. Choice A is incorrect because adequate hydration is generally recommended before the test. Choice C is incorrect as the nonstress test monitors the baby's heart rate in response to its own movements, not contractions. Choice D is incorrect as the nonstress test does not assess fetal lung maturity.