Nokea
The client enters the room of a client with Parkinson's disease who is taking carbidopa-levodopa. The client is arising slowly from the chair while the unlicensed assistive personnel (UAP) stands next to the chair. What action should the nurse take?
- A. Demonstrate how to help the client move more efficiently
- B. Offer a PRN analgesic to reduce painful movement
- C. Affirm that the client should arise slowly from the chair
- D. Tell the UAP to assist the client in moving more quickly
Correct Answer: A
Rationale: The correct action for the nurse to take in this situation is to demonstrate how to help the client move more efficiently. As the client is arising slowly from the chair, providing guidance on proper movement techniques can improve the client's mobility and safety. Offering a PRN analgesic (Choice B) is not relevant to the client's situation as there is no indication of pain. Affirming that the client should arise slowly (Choice C) does not address the need for assistance in improving movement efficiency. Instructing the UAP to assist the client in moving more quickly (Choice D) may compromise the client's safety and is not the appropriate action to take.
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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 client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol. Which intervention is most important for the nurse to include in this client's plan of care?
- A. Observe for bleeding side effects related to heparin therapy.
- B. Assess blood pressure and heart rate at least every 4 hours.
- C. Measure calf girth to evaluate edema in the affected leg.
- D. Encourage mobilization to prevent pulmonary embolism.
Correct Answer: A
Rationale: The correct answer is to 'Observe for bleeding side effects related to heparin therapy.' This is the most crucial intervention for a client with deep vein thrombosis (DVT) on a heparin protocol. Heparin, being an anticoagulant, increases the risk of bleeding as a side effect. Therefore, close monitoring for signs of bleeding, such as bruising, petechiae, or blood in stool or urine, is essential to prevent severe complications. While assessing blood pressure and heart rate (Choice B) is important, it is not as critical as monitoring for bleeding. Measuring calf girth (Choice C) may help evaluate edema but is not as vital as observing for bleeding complications. Encouraging mobilization (Choice D) is beneficial for preventing complications like pulmonary embolism, but in this scenario, monitoring for bleeding takes precedence due to the immediate risk associated with anticoagulant therapy.
After a motor vehicle collision, a client is admitted to the medical unit with acute adrenal insufficiency (Addisonian crisis). Which prescription should the nurse implement?
- A. Determine serum glucose levels
- B. Withhold potassium additives to IV fluids
- C. Give IV corticosteroid replacement
- D. Prepare to initiate IV vasopressors
Correct Answer: C
Rationale: In a client with acute adrenal insufficiency (Addisonian crisis) following a motor vehicle collision, the priority intervention is to administer IV corticosteroid replacement. This is crucial to manage the crisis by replacing the deficient cortisol. Determining serum glucose levels (Choice A) may be important but is not the immediate priority in this situation. Withholding potassium additives to IV fluids (Choice B) is not indicated and may exacerbate electrolyte imbalances. Initiating IV vasopressors (Choice D) is not the primary treatment for acute adrenal insufficiency and should be reserved for managing hypotension that is unresponsive to corticosteroid therapy.
A client who is bleeding after a vaginal delivery receives a prescription for methylergonovine (Methergine) 0.4 mg IM every 2 hours, not to exceed 5 doses. The medication is available in ampules containing 0.2 mg/ml. What is the maximum dosage in mg that the nurse should administer to this client? (Enter numeric value only)
- A. 2
- B. 3
- C. 4
- D. 5
Correct Answer: A
Rationale: To calculate the maximum dosage in mg that the nurse should administer, multiply the dose per administration (0.4 mg) by the maximum number of doses allowed (5 doses): 0.4 mg/dose * 5 doses = 2 mg. Therefore, the nurse should administer a maximum dosage of 2 mg to the client. Choices B, C, and D are incorrect as they do not reflect the correct calculation based on the provided information.
The client demonstrates an understanding of sliding scale insulin administration instructions by performing the procedure in which order?
- A. Obtain blood glucose level
- B. Verify the insulin prescription
- C. Draw insulin into insulin syringe
- D. Cleanse the selected site
Correct Answer: A
Rationale: The correct order for the client to perform the procedure is to first obtain the blood glucose level. This step is crucial as it helps determine the appropriate dose of insulin based on the sliding scale. Verifying the insulin prescription, drawing insulin into the syringe, and cleansing the selected site are important steps in the process but should follow after obtaining the blood glucose level. Therefore, options B, C, and D are incorrect in terms of the initial steps required for sliding scale insulin administration.