Nokea
The nurse is caring for a 10-year-old diagnosed with acute glomerulonephritis. Which outcome is the priority for this child?
- A. Activity tolerance as evidenced by appropriate age-level activities being performed
- B. Absence of skin breakdown as evidenced by intact skin and absence of redness
- C. Maintaining adequate nutritional status as evidenced by stable weight without gain or loss
- D. Maintaining fluid balance as evidenced by a urine output of 1 to 2 ml/kg/hr
Correct Answer: D
Rationale: The correct answer is D. In acute glomerulonephritis, the kidneys are inflamed, affecting fluid balance. Monitoring urine output of 1 to 2 ml/kg/hr is crucial to assess kidney function and prevent fluid overload or dehydration. This is the priority outcome as it directly reflects kidney function and overall fluid balance.
A: Activity tolerance is important but not the priority in acute glomerulonephritis.
B: Absence of skin breakdown is important for overall health but not directly related to the condition.
C: Nutritional status is important, but fluid balance takes precedence in managing acute glomerulonephritis.
In summary, maintaining fluid balance is crucial in managing acute glomerulonephritis as it directly reflects kidney function, while the other options are important but not the priority in this scenario.
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While assessing a client who is experiencing Cheyne-Stokes respirations, the nurse observes periods of apnea. What action should the nurse implement?
- A. Elevate the head of the client's bed
- B. Auscultate the client's breath sounds
- C. Measure the length of the apneic periods
- D. Suction the client's oropharynx
Correct Answer: C
Rationale: The correct answer is C: Measure the length of the apneic periods. This action is crucial in assessing the severity of Cheyne-Stokes respirations and guiding further interventions. By measuring the length of apneic periods, the nurse can determine the duration of respiratory pauses and their impact on oxygenation. This information helps in deciding the appropriate treatment, such as administering supplemental oxygen or notifying the healthcare provider. Elevating the head of the bed (choice A) can help with breathing but does not address the root cause. Auscultating breath sounds (choice B) is important but does not directly address the apneic periods. Suctioning the oropharynx (choice D) is not indicated unless there is an airway obstruction.
The nurse is assessing a client who is 2 days post-op following abdominal surgery. The client reports feeling something 'give way' in the incision site and there is a small amount of bowel protruding from the wound. What action should the nurse take first?
- A. Apply a sterile saline dressing to the wound
- B. Notify the healthcare provider
- C. Administer pain medication
- D. Cover the wound with an abdominal binder
Correct Answer: A
Rationale: The correct action for the nurse to take first is to apply a sterile saline dressing to the wound. This is because the client is experiencing evisceration, which is a medical emergency requiring immediate attention to prevent infection and further complications. By applying a sterile saline dressing, the nurse can protect the exposed bowel from contamination, maintain moisture, and promote healing. This action helps to reduce the risk of infection and provides a temporary barrier until further interventions can be implemented.
Summary of Incorrect Choices:
B: Notifying the healthcare provider is important, but immediate action to protect the exposed bowel is the priority.
C: Administering pain medication does not address the primary concern of protecting the exposed bowel.
D: Covering the wound with an abdominal binder does not provide the necessary protection and could potentially exacerbate the situation by applying pressure to the protruding bowel.
A client is taught how to collect a 24-hour urine specimen. Which statement indicates understanding of the procedure?
- A. I should keep the urine specimen refrigerated.
- B. I need to start the collection in the morning after my first void.
- C. I will collect the urine for 24 hours and keep it on ice.
- D. I will start collecting the urine after discarding my first morning specimen.
Correct Answer: D
Rationale: The correct answer is D because discarding the first morning specimen ensures accurate collection starts. Choice A is incorrect because refrigeration is unnecessary for a 24-hour urine collection. Choice B is incorrect as the first void should be included. Choice C is incorrect as there's no need to keep the urine on ice.
The nurse is caring for a client who is receiving a continuous intravenous infusion of heparin. Which laboratory value should the nurse monitor to evaluate the effectiveness of the therapy?
- A. Platelet count
- B. Prothrombin time (PT)
- C. Partial thromboplastin time (PTT)
- D. Hemoglobin level
Correct Answer: C
Rationale: The correct answer is C: Partial thromboplastin time (PTT). PTT measures the effectiveness of heparin therapy by assessing the clotting time. With heparin being an anticoagulant, monitoring PTT helps ensure the client is within the therapeutic range to prevent clot formation. A - Platelet count assesses risk of bleeding, not heparin effectiveness. B - Prothrombin time (PT) is used to monitor warfarin therapy, not heparin. D - Hemoglobin level monitors for anemia, not heparin effectiveness.
A client with a history of seizures is being discharged with a prescription for phenytoin (Dilantin). Which instruction should the nurse provide this client?
- A. Take the medication with meals
- B. Avoid alcohol while taking this medication
- C. Limit sodium intake
- D. Take the medication at bedtime
Correct Answer: B
Rationale: The correct answer is B: Avoid alcohol while taking this medication. Phenytoin interacts with alcohol, increasing the risk of side effects such as dizziness and drowsiness. Alcohol can also reduce the effectiveness of the medication. Taking the medication with meals (choice A) may help reduce gastrointestinal upset but does not address the alcohol interaction. Limiting sodium intake (choice C) is not directly related to phenytoin therapy. Taking the medication at bedtime (choice D) is not necessary for all clients and does not address the alcohol interaction.