Nokea
Several clients on a busy antepartum unit are scheduled for procedures that require informed consent. Which situation should the nurse explore further before witnessing the client's signature on the consent form?
- A. The client was medicated for pain with a narcotic analgesic IM 6 hours ago
- B. A 15-year-old primigravida who has been self-supporting for the past 6 months
- C. The obstetrician explained a procedure that a neurologist will perform
- D. The client is illiterate but verbalizes understanding and consent for the procedure
Correct Answer: D
Rationale: The correct answer is D because an illiterate client may require additional support to ensure they fully comprehend the information provided in the informed consent process. It is crucial to confirm that the client truly understands the nature of the procedure, its risks, and benefits. While it is important to assess pain control (choice A), a client's previous medication administration does not directly impact their ability to understand the consent process. Choice B, a 15-year-old primigravida who has been self-supporting, may legally provide informed consent depending on the jurisdiction and circumstances, so this situation may not require further exploration. Choice C, explaining a procedure by a different specialist, does not necessarily require additional exploration before witnessing the client's consent.
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A client with major depression who is taking fluoxetine calls the psychiatric clinic reporting being more agitated, irritable, and anxious than usual. Which intervention should the nurse implement?
- A. Tell the client to have a complete blood count (CBC) drawn
- B. Instruct the client to seek medical attention immediately
- C. Encourage them to take the medication at night with a snack
- D. Explain that these are common side effects of the medication
Correct Answer: B
Rationale: Increased agitation, irritability, and anxiety can be signs of serotonin syndrome or other serious side effects, not common side effects of fluoxetine. Instructing the client to seek medical attention immediately is crucial to address any potential serious adverse reactions. Option A is unnecessary as a CBC would not address the symptoms described. Option C is not the priority when serious side effects are suspected. Option D is incorrect as these symptoms should not be dismissed as common side effects.
The nurse is performing a peritoneal dialysis exchange on a client with chronic kidney disease (CKD). Which assessment finding should the nurse report to the healthcare provider?
- A. The appearance of the returning dialysate fluid is cloudy
- B. The client complains of slight shortness of breath during installation
- C. The amount of the returning dialysate fluid is greater than the amount instilled
- D. The client complains of abdominal fullness and cramping during instillation
Correct Answer: A
Rationale: Cloudy dialysate fluid can indicate peritonitis, a serious complication of peritoneal dialysis. Peritonitis is an urgent condition that requires immediate evaluation and treatment. Reporting this finding promptly is crucial to prevent further complications. Choices B, C, and D are not indicative of peritonitis and do not require immediate reporting to the healthcare provider. Complaining of slight shortness of breath, having a greater return volume, and experiencing abdominal fullness and cramping are common occurrences during peritoneal dialysis and do not necessarily indicate an emergent issue.
An older male client arrives at the clinic complaining that his bladder always feels full. He complains of a weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating his urine stream. What action should the nurse implement?
- A. Palpate the client's suprapubic area for distention
- B. Advise the client to maintain a voiding diary for one week
- C. Instruct the client in effective techniques for cleansing the glans penis
- D. Obtain a urine specimen for culture and sensitivity
Correct Answer: B
Rationale: Advising the client to maintain a voiding diary is the appropriate action in this case. A voiding diary helps track symptoms and patterns essential for diagnosing conditions like benign prostatic hyperplasia or other urinary issues. Palpating the client's suprapubic area for distention (Choice A) may provide information about bladder fullness but does not address the need for tracking symptoms. Instructing the client in techniques for cleansing the glans penis (Choice C) is not relevant to the client's urinary complaints. Obtaining a urine specimen for culture and sensitivity (Choice D) may be necessary but does not directly address the client's symptoms of weak urine flow and difficulty initiating the urine stream.
A mother brings her child, who has a history of asthma, to the emergency room. The child is wheezing and speaking one word between each breath. The child is anxious, tachycardic, and has labored respirations. Which assessment is most important for the nurse to obtain?
- A. Type of inhaler the child typically uses on a regular basis
- B. Frequency of rescue inhaler use during the week
- C. Last dose and type of rescue inhaler used by the child
- D. Type of allergen exposure or trigger for the current episode
Correct Answer: C
Rationale: The correct answer is C because knowing the last dose and type of rescue inhaler used helps assess if the child has received adequate treatment and if further intervention is needed. This information is crucial in managing an acute asthma exacerbation. Choice A, the type of inhaler the child typically uses, is less critical during an emergency. Choice B, the frequency of rescue inhaler use during the week, is important for general asthma management but does not provide immediate guidance in the acute situation. Choice D, the type of allergen exposure or trigger, is more relevant for preventive strategies and does not directly impact the immediate treatment of the child's acute asthma attack.
A 9-year-old received a short arm cast for a right radius. To relieve itching under the child's cast, which instructions should the nurse provide to the parents?
- A. Blow cool air from a hair dryer under the cast
- B. Twist the cast back and forth
- C. Shake powder into the cast
- D. Push a pencil under the cast edge
Correct Answer: A
Rationale: Blowing cool air from a hair dryer under the cast is a safe method to relieve itching without damaging the cast or causing injury. The air helps to dry out the moisture that is causing the itching. Twisting the cast back and forth (choice B) can create pressure points and discomfort for the child. Shaking powder into the cast (choice C) can introduce foreign material that may cause skin irritation. Pushing a pencil under the cast edge (choice D) can injure the child's skin or even dislodge the cast.