Nokea
The client has acute pancreatitis. Which nursing intervention is the highest priority?
- A. Administer pain medication as prescribed.
- B. Monitor the client's serum amylase and lipase levels.
- C. Encourage oral intake of clear liquids.
- D. Assess the client's bowel sounds every 4 hours.
Correct Answer: A
Rationale: The correct answer is A: Administer pain medication as prescribed. This is the highest priority because acute pancreatitis is a painful condition, and managing pain is crucial for the client's comfort and well-being. Pain control also helps reduce stress on the pancreas and can aid in preventing complications.
Choice B is incorrect because while monitoring serum amylase and lipase levels is important in diagnosing pancreatitis and assessing response to treatment, it is not the highest priority intervention.
Choice C is incorrect as encouraging oral intake of clear liquids may exacerbate pancreatitis symptoms and lead to further complications.
Choice D is incorrect as assessing bowel sounds, while important for monitoring gastrointestinal function, is not the highest priority in the acute management of pancreatitis.
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A client who has Type 1 diabetes and is at 10-weeks gestation comes to the prenatal clinic complaining of a headache, nausea, sweating, feeling shaky, and being tired all the time. What action should the nurse take first?
- A. Check the blood glucose level.
- B. Draw blood for a Hemoglobin A1C.
- C. Assess urine for ketone levels.
- D. Provide the client with a protein snack.
Correct Answer: A
Rationale: The correct answer is A: Check the blood glucose level. This is the first action the nurse should take because the client is presenting with symptoms of hypoglycemia, which can be life-threatening for a pregnant woman with Type 1 diabetes. By checking the blood glucose level, the nurse can determine if the client's symptoms are due to low blood sugar levels and take appropriate action. Drawing blood for a Hemoglobin A1C (choice B) is not the first priority in this acute situation. Assessing urine for ketone levels (choice C) is important in managing diabetes but is not the priority when the client is showing signs of hypoglycemia. Providing the client with a protein snack (choice D) may help raise blood sugar levels, but checking the blood glucose level is essential to determine the appropriate intervention.
A client with cirrhosis of the liver is being cared for by the healthcare team. Which clinical manifestation indicates that the client has developed hepatic encephalopathy?
- A. Asterixis.
- B. Jaundice.
- C. Ascites.
- D. Splenomegaly.
Correct Answer: A
Rationale: The correct answer is A: Asterixis. Hepatic encephalopathy is a neuropsychiatric syndrome associated with liver dysfunction. Asterixis, also known as liver flap, is a key clinical manifestation characterized by a flapping tremor of the hands when extended. This occurs due to impaired ammonia metabolism in the liver leading to neurotoxicity. Jaundice (B) is a sign of liver dysfunction but not specific to hepatic encephalopathy. Ascites (C) is the accumulation of fluid in the peritoneal cavity, common in liver cirrhosis but not indicative of hepatic encephalopathy. Splenomegaly (D) is enlargement of the spleen, which can occur in cirrhosis but is not a direct sign of hepatic encephalopathy.
Which assessment finding indicates a client's readiness to leave the nursing unit for a bronchoscopy?
- A. Client denies allergies to contrast media.
- B. Skin prep to insertion site completed.
- C. On-call sedation administered.
- D. Oxygen at 2 L/minute via nasal cannula.
Correct Answer: C
Rationale: Rationale: Option C, on-call sedation administered, is the correct answer because sedation is essential for bronchoscopy to ensure the client is comfortable and cooperative during the procedure. Sedation helps reduce anxiety and discomfort, making the procedure more tolerable. Options A, B, and D are incorrect as they do not directly indicate readiness for the procedure. Denying allergies to contrast media (A) is important but not specific to bronchoscopy readiness. Skin prep completion (B) is part of the pre-procedure preparation but does not confirm readiness. Oxygen administration (D) is a routine care measure and does not indicate readiness for bronchoscopy.
When a client reports being allergic to penicillin, which question should the nurse ask to gather more information?
- A. Are you allergic to any other medications?
- B. How often have you taken penicillin in the past?
- C. Is anyone else in your family allergic to penicillin?
- D. What happens to you when you take penicillin?
Correct Answer: D
Rationale: Rationale: Option D is the correct answer because it directly addresses the client's experience with penicillin, providing crucial details about the allergic reaction. By asking what happens when the client takes penicillin, the nurse gains specific information to assess the severity and type of allergic reaction. This helps in determining appropriate interventions and alternative medications. Options A, B, and C are incorrect as they do not focus on gathering detailed information about the client's allergic reaction to penicillin. Option A is too broad, option B is not relevant to the current situation, and option C does not directly address the client's individual experience.
In which situation is it most important for the registered nurse (RN) working on a medical unit to provide direct supervision?
- A. A graduate nurse needs to access a client's implanted port to start an infusion of Ringer's Lactate.
- B. A postpartum nurse pulled to the unit needs to start a transfusion of packed red blood cells.
- C. A practical nurse is preparing to assist the healthcare provider with a lumbar puncture at the bedside.
- D. An unlicensed assistive personnel is preparing to weigh an obese bedfast client using a bed scale.
Correct Answer: A
Rationale: The correct answer is A because accessing an implanted port for infusion is a specialized skill that requires direct supervision to ensure the safety and accuracy of the procedure. Step 1: A graduate nurse may not have sufficient experience with accessing ports. Step 2: The RN needs to ensure proper technique and prevent complications. Step 3: Direct supervision allows for immediate intervention if any issues arise. Other choices are incorrect because B: starting a transfusion is within the scope of practice for a nurse, C: assisting with a lumbar puncture can be done under indirect supervision, and D: weighing a client is a task that can be delegated to unlicensed personnel with proper training.