Nokea
The client has received 250 ml of 0.9% normal saline through the IV line in the last hour. The client is now tachypneic and has a pulse rate of 120 beats/minute, with a pulse volume of +4. In addition to reporting the assessment findings to the healthcare provider, what action should the nurse implement?
- A. Discontinue the IV and apply pressure at the site.
- B. Decrease the saline to a keep-open rate.
- C. Increase the rate of the current IV solution.
- D. Change the IV fluid to 0.45% normal saline at the same rate.
Correct Answer: B
Rationale: The correct answer is B: Decrease the saline to a keep-open rate. The client is showing signs of fluid overload, indicated by tachypnea and bounding pulse. By decreasing the saline to a keep-open rate, the nurse can prevent further fluid overload while maintaining IV access. Discontinuing the IV and applying pressure (choice A) is not necessary unless there is a specific issue with the IV site. Increasing the rate of the current IV solution (choice C) would worsen the fluid overload. Changing the IV fluid to 0.45% normal saline (choice D) at the same rate may not effectively address the fluid overload concern.
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A male infant born at 30-weeks gestation at an outlying hospital is being prepared for transport to a Level IV neonatal facility. His respirations are 90/min, and his heart rate is 150 beats per minute. Which drug is the transport team most likely to administer to this infant?
- A. Ampicillin (Omnipen) 25 mg/kg slow IV push.
- B. Gentamicin sulfate (Garamycin) 2.5 mg/kg IV.
- C. Digoxin (Lanoxin) 20 micrograms/kg IV.
- D. Beractant (Survanta) 100 mg/kg per endotracheal tube.
Correct Answer: D
Rationale: The correct answer is D: Beractant (Survanta) 100 mg/kg per endotracheal tube. In this scenario, the infant's high respiratory rate indicates respiratory distress, likely due to immature lungs. Beractant is a pulmonary surfactant used to treat respiratory distress syndrome in preterm infants by improving lung function and reducing the risk of complications. Administering beractant via endotracheal tube helps deliver the medication directly to the lungs.
Choice A (Ampicillin) is an antibiotic used for treating infections, not respiratory distress. Choice B (Gentamicin) is an antibiotic for infections, not respiratory distress. Choice C (Digoxin) is a cardiac medication for heart conditions, not respiratory distress. Therefore, only choice D addresses the respiratory distress issue in the preterm infant, making it the most appropriate drug for the transport team to administer in this case.
What action should the healthcare provider take to reduce the risk of vesicant extravasation in a client receiving intravenous chemotherapy?
- A. Administer an antiemetic before starting the chemotherapy.
- B. Instruct the client to drink plenty of fluids during the treatment.
- C. Keep the head of the bed elevated until the treatment is completed.
- D. Monitor the client's intravenous site hourly during the treatment.
Correct Answer: D
Rationale: The correct answer is D: Monitor the client's intravenous site hourly during the treatment. This is crucial to reduce the risk of vesicant extravasation, which can cause tissue damage if the chemotherapy leaks into the surrounding tissues. By monitoring the IV site hourly, the healthcare provider can detect any signs of infiltration or extravasation early and take necessary actions to prevent further harm.
A: Administering an antiemetic before starting chemotherapy is unrelated to preventing vesicant extravasation.
B: Instructing the client to drink plenty of fluids does not directly address the risk of vesicant extravasation.
C: Keeping the head of the bed elevated is not specific to preventing vesicant extravasation and may not effectively reduce the risk.
The client with newly diagnosed osteoporosis is being taught by the nurse about dietary modifications. Which instruction should the nurse include?
- A. Increase your intake of high-calcium foods.
- B. Limit your intake of vitamin D-rich foods.
- C. Avoid foods high in phosphorus.
- D. Increase your intake of high-sodium foods.
Correct Answer: A
Rationale: The correct answer is A: Increase your intake of high-calcium foods. Osteoporosis is a condition characterized by low bone density, and calcium is essential for bone health. Increasing calcium intake can help strengthen bones and prevent further bone loss. Foods high in calcium, such as dairy products, leafy green vegetables, and fortified foods, are beneficial for individuals with osteoporosis.
Summary of other choices:
B: Limiting intake of vitamin D-rich foods is not advised, as vitamin D plays a crucial role in calcium absorption and bone health.
C: Avoiding foods high in phosphorus is not necessary, as phosphorus is also important for bone health and overall body function.
D: Increasing intake of high-sodium foods is not recommended, as high sodium intake can lead to calcium loss from the bones, worsening osteoporosis.
A 60-year-old male client is admitted to the hospital with the complaint of right knee pain for the past week. His right knee and calf are warm and edematous. He has a history of diabetes and arthritis. Which neurological assessment action should the nurse perform for this client?
- A. Glasgow Coma Scale
- B. Assess pulses, paresthesia, and paralysis distal to the right knee
- C. Assess pulses, paresthesia, and paralysis proximal to the right knee
- D. Optic nerve using an ophthalmoscope
Correct Answer: B
Rationale: The correct answer is B: Assess pulses, paresthesia, and paralysis distal to the right knee. This is the appropriate action because the client presents with warm, edematous right knee and calf, indicating a potential vascular issue like deep vein thrombosis (DVT). Assessing pulses, paresthesia, and paralysis distal to the right knee helps evaluate circulation and nerve function, crucial in identifying complications of DVT. Glasgow Coma Scale (A) is used to assess consciousness, not relevant in this case. Assessing proximal pulses, paresthesia, and paralysis (C) may not provide accurate information about circulation distal to the knee. Evaluating the optic nerve (D) using an ophthalmoscope is unrelated to the client's presenting symptoms and medical history.
A client is undergoing chemotherapy and is at risk for developing thrombocytopenia. What precaution should the nurse teach the client to minimize the risk of bleeding?
- A. Use a soft-bristled toothbrush.
- B. Engage in daily aerobic exercise.
- C. Take aspirin for headaches.
- D. Use an electric razor for shaving.
Correct Answer: A
Rationale: The correct answer is A: Use a soft-bristled toothbrush. Chemotherapy can cause low platelet levels, increasing the risk of bleeding. Using a soft-bristled toothbrush can help prevent gum bleeding and trauma to the gums, reducing the risk of bleeding. Engaging in daily aerobic exercise (B) can increase the risk of injury and bleeding for a client with thrombocytopenia. Taking aspirin (C) can further decrease platelet function and increase bleeding risk. Using an electric razor (D) is recommended to prevent skin cuts and bleeding due to the fragile skin associated with chemotherapy-induced thrombocytopenia.