Nokea
The newly hired nurse cares for a client bitten by a venomous snake in the left hand. Which of the following interventions by the newly hired nurse requires follow-up by the charge nurse?
- A. Applying a tourniquet proximal to the bite.
- B. Removing the client's wristwatch and jewelry.
- C. Establishing intravenous (IV) access.
- D. Obtaining a type and crossmatch for fresh frozen plasma (FFP).
Correct Answer: A
Rationale: Applying a tourniquet can worsen tissue damage by restricting blood flow and concentrating venom, requiring follow-up. Removing jewelry (B) prevents constriction from swelling, establishing IV access (C) is essential for antivenom administration, and type and crossmatch (D) may be appropriate for potential complications.
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A client has the following arterial blood gas values: pH, 7.52; PaO2, 50 mm Hg; PaCO2, 28 mm Hg; HCO3ˆ’, 24 mEq/L. Based upon the client's PaO2, which of the following conclusions would be accurate?
- A. The client is severely hypoxic.
- B. The client is low but poses no risk for the client.
- C. The client's PaO2 level is within normal range.
- D. The client requires oxygen therapy with very low oxygen concentrations.
Correct Answer: A
Rationale: A PaO2 of 50 mm Hg indicates severe hypoxia (normal is 75–100 mm Hg), requiring urgent oxygen therapy. It poses significant risk and is not normal or manageable with low concentrations.
A client with a history of renal calculi formation is being discharged after surgery to remove the calculus. What instructions should the nurse include in the client's discharge teaching plan?
- A. Increase daily fluid intake to at least 2 to 3 L.
- B. Strain urine at home regularly.
- C. Eliminate dairy products from the diet.
- D. Follow measures to alkalinize the urine.
Correct Answer: A,B
Rationale: High fluid intake (2-3 L) prevents stone recurrence, and straining urine monitors for stone passage. Dairy restriction or urine alkalinization depends on stone type.
A client has vertigo. Which of the following actions would be most appropriate for the nursing diagnosis of Risk for injury related to altered immobility and gait disturbances? Select all that apply.
- A. The client assumes safe position when dizzy.
- B. The client experiences no falls.
- C. The client performs vestibular/balance exercises.
- D. The client demonstrates family involvement.
- E. The client keeps head still when dizzy.
Correct Answer: A,B,C,E
Rationale: Appropriate actions include assuming a safe position (e.g., sitting or lying down), preventing falls, performing vestibular exercises to improve balance, and keeping the head still during vertigo to minimize symptoms and reduce injury risk.
For a client who excretes excessive amounts of calcium during the postoperative period after open heart surgery, which of the following measures should the nurse institute to help prevent complications associated with excessive calcium excretion?
- A. Ensure a liberal fluid intake.
- B. Provide an alkaline-ash diet.
- C. Prevent constipation.
- D. Enrich the client's diet with dairy products.
Correct Answer: A
Rationale: Liberal fluid intake promotes calcium excretion through urine, preventing complications like kidney stones or hypercalcemia.
Although all of the following measures might be useful in reducing the visual disability of a client with adult macular degeneration (AMD), which measure should the nurse teach the client primarily as a safety precaution?
- A. Wear a patch over one eye.
- B. Place personal items on the sighted side.
- C. Lie in bed with the unaffected side toward the door.
- D. Turn the head from side to side when walking.
Correct Answer: B
Rationale: Placing personal items on the sighted side enhances safety by ensuring the client can see and access items easily, reducing the risk of falls or accidents.