Nokea
The nurse has asked the nursing assistant to ambulate a client with Parkinson's disease. The nurse observes the nursing assistant pulling on the client's arms to get the client to walk forward. The nurse should:
- A. Have the nursing assistant keep a steady pull on the client to promote forward ambulation.
- B. Explain how to overcome a freezing gait by telling the client to march in place.
- C. Assist the nursing assistant with getting the client back in bed.
- D. Give the client a muscle relaxant.
Correct Answer: B
Rationale: Teaching the client to march in place helps overcome freezing gait, a common Parkinson's symptom. Pulling on arms is unsafe, returning to bed is unnecessary, and muscle relaxants are inappropriate.
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A client was admitted to the hospital with iron deficiency anemia and blood-streaked emesis. Which question is most appropriate for the nurse to ask in determining the extent of the client's activity intolerance?
- A. What daily activities were you able to do 6 months ago compared with the present?'
- B. How long have you had this problem?'
- C. Have you been able to keep up with all your usual activities?'
- D. Are you more tired now than you used to be?'
Correct Answer: A
Rationale: To assess activity intolerance, the nurse should compare the client's current activity level with their previous capabilities. Asking about specific activities performed 6 months ago versus now provides concrete data on the extent of intolerance. The other questions are less specific and do not directly quantify changes in activity capacity.
A nurse is assessing a client with a urinary tract infection who takes an antihypertensive drug. The nurse reviews the client’s urinalysis results (see chart). The nurse should:
- A. Encourage the client to increase fl uid intake.
- B. Withhold the next dose of antihypertensive medication.
- C. Restrict the client’s sodium intake.
- D. Encourage the client to eat at least half of a banana per day
Correct Answer: A
Rationale: The client’s urine specifi c gravity is elevated. Specific gravity is a refl ection of the concentrating ability of the kidneys. This level indicates that the urine is concentrated. By increasing fluid intake, the urine will become more dilute. Antihypertensives do not make urine more concentrated unless there is a diuretic component within them. The nurse should not hold a dose of antihypertensive medication. Sodium tends to pull water with it; by restricting sodium, less water, not more, will be present. Bananas do not aid in the dilution of urine.
A client is receiving fluid replacement with Lactated Ringer's after 40% of his body was burned 10 voluto hours ago. The assessment reveals: temperature 36.2°C; heart rate 122; blood pressure 84/42; CVP 2 mm Hg; and urine output 25 mL for the last 2 hours. The I.V. rate is currently at 375 mL/hour. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the healthcare provider with the recommendation for:
- A. Furosemide (Lasix).
- B. Fresh frozen plasma.
- C. I.V. rate increase.
- D. Dextrose 5%.
Correct Answer: C
Rationale: Low blood pressure, high heart rate, low CVP, and inadequate urine output indicate hypovolemia. Increasing the I.V. rate is appropriate to improve fluid resuscitation, as per burn fluid management protocols.
A client is having a blood transfusion reaction. The nurse must do the following in what order of priority from first to last?
- A. Notify the attending physician and blood bank.
- B. Complete the appropriate Transfusion Reaction Form(s).
- C. Stop the transfusion.
- D. Keep the I.V. open with normal saline infusion.
Correct Answer: C,D,A,B
Rationale: In a transfusion reaction, the nurse must first stop the transfusion to prevent further infusion of the offending blood. Next, keep the IV line open with normal saline to maintain access and support circulation. Then, notify the physician and blood bank for further evaluation and management. Finally, complete the transfusion reaction forms to document the incident.
When performing external chest compressions on an adult during cardiopulmonary resuscitation (CPR), the rescuer should depress the sternum:
- A. 0.5 to 1 inch.
- B. 1 to 1.5 inches.
- C. 1.5 to 2 inches.
- D. 2 to 2.5 inches.
Correct Answer: C
Rationale: Depressing the sternum 1.5 to 2 inches ensures adequate compression depth for effective CPR in adults, per guidelines.