Nokea
The nurse is assessing a client who has a new cast on the left arm. Which finding should the nurse report to the healthcare provider immediately?
- A. Client reports itching under the cast
- B. Client reports pain at the cast site
- C. Client reports swelling of the fingers
- D. Client reports warmth over the casted area
Correct Answer: C
Rationale: Swelling of the fingers can indicate compromised circulation, which is a serious concern in a client with a new cast. It could suggest the development of compartment syndrome, a condition where increased pressure within the muscles can lead to impaired blood flow. This can result in tissue damage and should be addressed promptly. Itching under the cast, pain at the cast site, and warmth over the casted area are common findings after cast application and may not necessarily indicate an urgent issue requiring immediate reporting to the healthcare provider.
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A client with a history of heart failure is admitted to the hospital with worsening dyspnea. The nurse notes that the client has a productive cough with pink, frothy sputum. What action should the nurse take first?
- A. Administer oxygen
- B. Perform chest physiotherapy
- C. Elevate the head of the bed
- D. Obtain a sputum specimen
Correct Answer: A
Rationale: In a client with heart failure presenting with worsening dyspnea and pink, frothy sputum (indicating pulmonary edema), the priority action for the nurse is to administer oxygen. Oxygen therapy helps improve oxygenation and alleviate dyspnea by increasing the oxygen supply to the lungs. Performing chest physiotherapy, elevating the head of the bed, or obtaining a sputum specimen are not the initial actions indicated in this situation and may delay addressing the client's immediate need for improved oxygenation.
The nurse observes a client in a wheelchair with a vest restraint in place. What nursing intervention is most important for the nurse to implement?
- A. Assess the need for continued restraint
- B. Check the client for urinary incontinence
- C. Determine skin integrity under the vest
- D. Perform range-of-motion exercises on extremities
Correct Answer: A
Rationale: The correct answer is to assess the need for continued restraint. This is the most important nursing intervention as it ensures the client's safety and autonomy. Checking for urinary incontinence (Choice B) may be important but is not the priority in this situation. Determining skin integrity under the vest (Choice C) is essential but not as crucial as assessing the need for continued restraint. Performing range-of-motion exercises (Choice D) is important for client mobility but not the priority when a restraint is in place.
Which nursing diagnosis has the highest priority when planning care for a client in cardiogenic shock?
- A. Risk for imbalanced body temperature
- B. Excess fluid volume
- C. Fatigue
- D. Ineffective Tissue Perfusion
Correct Answer: D
Rationale: In cardiogenic shock, the priority nursing diagnosis is Ineffective Tissue Perfusion. This diagnosis indicates that the client is not receiving adequate oxygenated blood to tissues, putting vital organs at risk. Addressing ineffective tissue perfusion is crucial to prevent organ damage and ensure the client's survival. The other options, such as 'Risk for imbalanced body temperature,' 'Excess fluid volume,' and 'Fatigue,' are important but secondary to the immediate threat of inadequate tissue perfusion in cardiogenic shock.
A client diagnosed with tuberculosis (TB) is placed on drug therapy with rifampin (Rifadin). The client should be instructed to report which effect(s) of the medication to the healthcare provider?
- A. Reddish-orange discoloration of body fluids
- B. Bloody or blood-tinged urine
- C. Blurring of vision
- D. Weight gain of more than 2 pounds in a week
Correct Answer: A
Rationale: The correct answer is A. Rifampin (Rifadin) commonly causes a reddish-orange discoloration of body fluids, including urine, sweat, saliva, and tears. This is a harmless side effect but should be reported to the healthcare provider for monitoring. Choices B, C, and D are not typically associated with rifampin therapy. Bloody or blood-tinged urine may indicate other issues such as urinary tract infection or kidney problems, blurring of vision may suggest eye problems, and significant weight gain could be related to various health conditions unrelated to rifampin.
The nurse is preparing to administer the 0800 dose of 20 units of Humulin R to an 8-year-old girl diagnosed with Type 1 diabetes. The mother comments that her daughter is a very picky eater and many times does not eat meals. Which intervention should the nurse implement first?
- A. Administer the 20 Units of Humulin R subcutaneously as prescribed
- B. Ask the girl if she will be eating her breakfast this morning
- C. Discuss changing the insulin prescription to Lispro with the healthcare provider
- D. Explain to the mother the importance of eating the scheduled meals
Correct Answer: B
Rationale: The correct answer is to ask the girl if she will be eating her breakfast this morning. This is important to determine if the child will be consuming food, which is crucial information before administering insulin. If the child does not plan to eat, administering the full dose of insulin may lead to hypoglycemia. Choice A is incorrect as administering the insulin without knowing if the child will eat can be dangerous. Choice C is not the first intervention because the immediate concern is the child's meal intake. Choice D, while important, is not the first step in this situation.