Nokea
The charge nurse observes that a client with a nasogastric tube on low intermittent suction is drinking a glass of water immediately after the unlicensed assistive personnel (UAP) left the room. What action should the nurse take?
- A. Remove the glass of water and speak to the UAP.
- B. Discuss the incident with the UAP at the end of the day.
- C. Write an incident report and notify the healthcare provider.
- D. Remind the client of the potential for electrolyte imbalance.
Correct Answer: A
Rationale: The correct answer is A: Remove the glass of water and speak to the UAP. The rationale is as follows: 1) Drinking water with low intermittent suction can cause complications. 2) Immediate action is necessary to prevent harm. 3) Speaking to the UAP clarifies the situation and provides education. 4) Removing the glass of water ensures the client's safety.
Incorrect choices:
B: Discussing at the end of the day delays action and puts the client at risk.
C: Writing an incident report is important, but immediate intervention is needed first.
D: Reminding the client of electrolyte imbalance does not address the current issue of drinking water with a nasogastric tube.
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A patient with chronic heart failure is prescribed furosemide. What is the primary action of this medication?
- A. Increase cardiac output
- B. Reduce fluid retention
- C. Decrease heart rate
- D. Lower blood pressure
Correct Answer: B
Rationale: The correct answer is B: Reduce fluid retention. Furosemide is a loop diuretic that works by increasing urine production, leading to the removal of excess fluid and sodium from the body. This helps reduce fluid volume overload in conditions like heart failure. Choice A is incorrect because while reducing fluid retention may indirectly improve cardiac output by reducing preload, furosemide itself does not directly increase cardiac output. Choice C is incorrect as furosemide does not have a direct effect on heart rate. Choice D is incorrect because while furosemide may lower blood pressure as a result of reducing fluid volume, its primary action is to reduce fluid retention, not specifically lower blood pressure.
A patient with chronic kidney disease (CKD) is prescribed erythropoietin. What is the primary action of this medication?
- A. Stimulate white blood cell production
- B. Increase platelet count
- C. Promote red blood cell production
- D. Enhance clotting factor production
Correct Answer: C
Rationale: The correct answer is C: Promote red blood cell production. Erythropoietin is a hormone that stimulates the production of red blood cells in the bone marrow. This is crucial for patients with CKD who often develop anemia due to decreased erythropoietin production.
A: Stimulating white blood cell production is the function of other medications, such as colony-stimulating factors, not erythropoietin.
B: Erythropoietin does not have an effect on platelet count.
D: Enhancing clotting factor production is not the primary action of erythropoietin.
The healthcare provider formulates a nursing diagnosis of 'High risk for ineffective airway clearance' for a client with myasthenia gravis. What is the most likely cause for this nursing diagnosis?
- A. Pain during coughing.
- B. Diminished cough effort.
- C. Thick, dry secretions.
- D. Excessive inflammation.
Correct Answer: B
Rationale: The correct answer is B: Diminished cough effort. In myasthenia gravis, muscle weakness can affect the muscles involved in coughing, leading to diminished cough effort. This can result in ineffective airway clearance, putting the client at high risk for respiratory complications. Pain during coughing (choice A) may occur but is not the primary cause of ineffective airway clearance in myasthenia gravis. Thick, dry secretions (choice C) and excessive inflammation (choice D) may contribute to airway clearance issues but are not as directly related to the underlying muscle weakness seen in myasthenia gravis.
Aspirin is prescribed for a 9-year-old child with rheumatic fever to control the inflammatory process, promote comfort, and reduce fever. What intervention is most important for the nurse to implement?
- A. Instruct the parents to hold the aspirin until the child has first had a tepid sponge bath.
- B. Administer the aspirin with at least two ounces of water or juice.
- C. Notify the healthcare provider if the child complains of ringing in the ears.
- D. Advise the parents to question the child about seeing yellow halos around objects.
Correct Answer: C
Rationale: The correct answer is C: Notify the healthcare provider if the child complains of ringing in the ears. This is important because ringing in the ears can be a sign of salicylate toxicity, a potential side effect of aspirin use in children with rheumatic fever. It is crucial to monitor for this symptom to prevent serious complications.
A: Instructing the parents to hold the aspirin until the child has a tepid sponge bath is not the most important intervention. Managing salicylate toxicity takes precedence over comfort measures.
B: Administering the aspirin with at least two ounces of water or juice is a general guideline for medication administration but not the most critical intervention in this scenario.
D: Advising the parents to question the child about seeing yellow halos around objects is not directly related to the potential side effects of aspirin in this case. Monitoring for salicylate toxicity through symptoms like ringing in the ears is more crucial.
A patient with bipolar disorder is prescribed valproic acid. What is an important side effect for the nurse to monitor?
- A. Hypertension
- B. Liver toxicity
- C. Hyperglycemia
- D. Bradycardia
Correct Answer: B
Rationale: Correct Answer: B (Liver toxicity)
Rationale:
1. Valproic acid is known to cause liver toxicity.
2. The nurse should monitor liver function tests regularly.
3. Signs of liver toxicity include jaundice, abdominal pain, and nausea.
4. Prompt detection is crucial to prevent serious complications.
Summary:
A: Hypertension - Not a common side effect of valproic acid.
C: Hyperglycemia - More commonly associated with other medications like antipsychotics.
D: Bradycardia - Not a typical side effect of valproic acid.