Nokea
The client with diabetes mellitus type 1 has a fruity breath odor. What is the priority nursing action?
- A. Evaluate the client's intake and output
- B. Measure the client's capillary blood glucose
- C. Consult with the dietitian about the client's diet
- D. Apply a pulse oximeter to the client's finger
Correct Answer: B
Rationale: Fruity breath odor in a client with diabetes mellitus type 1 can indicate ketoacidosis, a serious complication. Measuring the client's capillary blood glucose is the priority nursing action in this scenario as it helps diagnose and manage the condition effectively. Evaluating intake and output may be important for overall assessment but not the priority when dealing with a potential emergency like ketoacidosis. Consulting with a dietitian about the client's diet is important for long-term management but not the immediate priority. Applying a pulse oximeter is not relevant to addressing the fruity breath odor and suspected ketoacidosis.
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Several clients on a telemetry unit are scheduled for discharge in the morning, but a telemetry-monitored bed is needed immediately. The charge nurse should make arrangements to transfer which client to another medical unit? The client who is
- A. Learning to self-administer insulin injections after being diagnosed with diabetes mellitus
- B. Ambulatory following coronary artery bypass graft surgery performed six days ago.
- C. Wearing a sling immobilizer following permanent pacemaker insertion earlier that day
- D. Experiencing syncopal episodes resulting from dehydration caused by severe diarrhea
Correct Answer: B
Rationale: The correct answer is B because the client who is ambulatory following coronary artery bypass graft surgery performed six days ago is stable enough for transfer compared to the other clients. Choice A should not be transferred as the client is still in the learning phase of self-administering insulin injections after being diagnosed with diabetes mellitus, requiring close monitoring. Choice C should not be transferred immediately after having a permanent pacemaker insertion as they need telemetry monitoring for any complications. Choice D should not be transferred as the client is experiencing syncopal episodes due to dehydration caused by severe diarrhea, requiring immediate intervention and close monitoring on the telemetry unit.
The nurse administers an oral antiviral to a client with shingles. Which finding is most important for the nurse to report to the healthcare provider?
- A. Decreased white blood cell count
- B. Pruritus and muscle aches
- C. Elevated liver function tests
- D. Vomiting and diarrhea
Correct Answer: C
Rationale: The correct answer is C: Elevated liver function tests. When administering antivirals, especially orally, monitoring liver function tests is crucial as it may indicate liver toxicity. This finding should be reported promptly to the healthcare provider to prevent further complications. Choice A, decreased white blood cell count, may be expected with certain antivirals but is not the most critical finding in this scenario. Pruritus and muscle aches (choice B) are common side effects of antivirals and do not require immediate reporting. Vomiting and diarrhea (choice D) are also common side effects that may not be as concerning as elevated liver function tests.
After changing to a new brand of laundry detergent, an adult male reports that he has a fine itchy rash. Which assessment finding warrants immediate intervention by the nurse?
- A. Bilateral Wheezing
- B. Urticaria
- C. Peripheral edema
- D. Elevated blood pressure
Correct Answer: B
Rationale: The correct answer is B: Urticaria. An itchy rash following a change in detergent may indicate an allergic reaction, specifically urticaria (hives), which requires immediate attention. Urticaria can be a sign of a severe allergic reaction, such as anaphylaxis. Bilateral wheezing (choice A) may suggest respiratory issues like asthma but is not directly related to the skin rash. Peripheral edema (choice C) and elevated blood pressure (choice D) are not typically associated with an allergic reaction to laundry detergent and would not be the priority assessment findings in this scenario.
A client is admitted with pyelonephritis, and cultures reveal an Escherichia coli infection. The client is allergic to penicillins, and the healthcare provider prescribed vancomycin IV. The nurse should plan to carefully monitor the client for which finding during IV administration?
- A. Tissue sloughing upon extravasation
- B. Elevated blood pressure and heart rate
- C. Tinnitus and vertigo
- D. Erythema of the face, neck, and chest
Correct Answer: C
Rationale: The correct answer is C: Tinnitus and vertigo. Vancomycin can cause ototoxicity and nephrotoxicity, leading to symptoms like tinnitus and vertigo. Monitoring for these adverse effects is crucial to prevent further complications. Choices A, B, and D are incorrect because tissue sloughing, elevated blood pressure and heart rate, and erythema of the face, neck, and chest are not typically associated with vancomycin administration. Therefore, the nurse should focus on monitoring for signs of ototoxicity and nephrotoxicity such as tinnitus and vertigo.
The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN?
- A. Transport a client who is receiving IV fluid to the radiology department
- B. Administer PRN oral analgesics to a client with a history of chronic pain
- C. Supervise a newly hired graduate nurse during an admission assessment
- D. Complete ongoing focused assessments of a client with wrist restraints
Correct Answer: C
Rationale: The correct answer is C because supervising a newly hired graduate nurse during an admission assessment is a task that falls within the registered nurse's scope of practice. Registered nurses are responsible for overseeing and delegating tasks, especially to new staff, to ensure proper assessment and care delivery. Choices A, B, and D involve tasks that can be appropriately assigned to practical nurses or unlicensed assistive personnel as they are within their scope of practice. Transporting a client, administering oral analgesics, and completing focused assessments do not require the advanced knowledge and skills of a registered nurse.