Nokea
The client is diagnosed with Multi Organ Dysfunction Syndrome (MODS). Which is the most appropriate goal for the nurse to write when planning the client's care?
- A. The client will maintain vital signs within normal limits during the next 24 hours.
- B. The client's urine output will be maintained to achieve output of 600 mL in the next 24 hours.
- C. The client will have elevated ALT, AST, and GGT liver enzymes within the next 24 hours.
- D. The client's blood glucose reading will be 200 to 240 mg/dL for the next 24 hours.
Correct Answer: A
Rationale: Maintaining normal vital signs is a broad, achievable goal in MODS. Urine output is specific, elevated enzymes are undesirable, and high glucose is not a goal.
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The client comes to the emergency department complaining of dyspnea and wheezing after eating at a seafood restaurant. The client cannot speak and has a bluish color around the mouth. Which intervention should the nurse implement first?
- A. Initiate an IV with normal saline.
- B. Prepare to intubate the client.
- C. Administer oxygen at 100%.
- D. Ask the client about an iodine allergy.
Correct Answer: C
Rationale: Administering 100% oxygen addresses immediate hypoxia in anaphylaxis, per ABCs. IV fluids, intubation, and allergy history follow.
The health-care provider scheduled a lumbar puncture for a client admitted with rule-out Guillain-Barré syndrome. Which preprocedure intervention has priority?
- A. Keep the client NPO.
- B. Instruct the client to void.
- C. Place in the lithotomy position.
- D. Assess the client's pedal pulse.
Correct Answer: B
Rationale: Voiding before a lumbar puncture prevents discomfort and reduces complications. NPO is unnecessary, lithotomy is incorrect, and pedal pulse is irrelevant.
The client is diagnosed with myasthenia gravis. Which intervention should the nurse implement when administering the anticholinesterase pyridostigmine (Mestinon)?
- A. Administer the medication 30 minutes prior to meals.
- B. Instruct the client to take with eight (8) ounces of water.
- C. Explain the importance of sitting up for one (1) hour after taking medication.
- D. Assess the client's blood pressure prior to administering medication.
Correct Answer: A
Rationale: Administering pyridostigmine 30 minutes before meals maximizes muscle strength for swallowing. Water volume, sitting up, and BP checks are not specific requirements.
Which is the highest priority nursing intervention for the client who is having an anaphylactic reaction?
- A. Administer parenteral epinephrine, an adrenergic agonist.
- B. Prepare for immediate endotracheal intubation.
- C. Provide a calm assurance when caring for the client.
- D. Establish and maintain a patent airway.
Correct Answer: D
Rationale: Establishing a patent airway is the highest priority in anaphylaxis, per ABCs. Epinephrine, intubation, and reassurance follow.
Which sign/symptom should the nurse expect to assess in the client who is in the recovery stage of Guillain-Barré syndrome?
- A. Decreasing deep tendon reflexes.
- B. Drooping of the eyelids has resolved.
- C. A positive Babinski's reflex.
- D. Descending increase in muscle strength.
Correct Answer: D
Rationale: Recovery in Guillain-Barré syndrome shows descending muscle strength improvement. Reflexes improve, ptosis is unrelated, and Babinski’s is not typical.