Nokea
The nurse is caring for a client diagnosed with pneumonia. When considering the client's safety, when will the nurse plan to take the client for a short walk?
- A. After the client eats lunch
- B. After the client has a brief nap
- C. After the client uses the metered-dose inhaler
- D. After assessing the client's oxygen saturation
Correct Answer: C
Rationale: The nurse should schedule activities for the client with pneumonia after the client has received respiratory treatments or medications. After the administration of bronchodilators (often administered by metered-dose inhaler), the client has the best oxygen exchange possible and would tolerate the activity best. Still, the nurse implements activity cautiously, so as not to increase the client's dyspnea. The client would become fatigued after eating; therefore, this is not a good time to ambulate the client. Although the client may be rested somewhat after a nap, the respiratory status of the client may not be at its best. Although monitoring oxygen saturation is appropriate, the intervention itself does not affect the client's respiratory function.
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The nurse has a prescription to ambulate a client with a nephrostomy tube four times a day. The nurse determines that the safest way to ambulate the client while maintaining the integrity of the nephrostomy tube is to implement which intervention?
- A. Change the drainage bag to a leg collection bag.
- B. Tie the drainage bag to the client's waist while ambulating.
- C. Use a walker to hang the drainage bag from while ambulating.
- D. Tell the client to hold the drainage bag higher than the level of the bladder.
Correct Answer: A
Rationale: The safest approach to protect the integrity and safety of the nephrostomy tube with a mobile client is to attach the tube to a leg collection bag. This allows for greater freedom of movement, while preventing accidental disconnection or dislodgment. The drainage bag is kept below the level of the bladder. Option 3 presents the risk of tension or pulling on the nephrostomy tube by the client during ambulation.
The nurse is caring for a client diagnosed with preeclampsia. When the client's condition progresses from preeclampsia to eclampsia, what should the nurse's first action be?
- A. Maintain an open airway.
- B. Administer oxygen by face mask.
- C. Assess the maternal blood pressure and fetal heart tones.
- D. Administer an intravenous infusion of magnesium sulfate.
Correct Answer: A
Rationale: Eclampsia is characterized by the occurrence of seizures. If the client experiences seizures, it is important as a first action to establish and maintain an open airway and prevent injuries to the client. Options 2, 3, and 4 are all interventions that should be done but not initially.
The primary health care provider prescribes a dose of intravenous (IV) potassium chloride for a client. When administering the IV potassium chloride, which action should the nurse take?
- A. Inject it as a bolus.
- B. Use a filter in the IV line.
- C. Dilute it per medication instructions.
- D. Apply cool compresses to the IV site.
Correct Answer: C
Rationale: Potassium chloride is very irritating to the vein and must be diluted to prevent phlebitis and is administered using an IV pump. Potassium chloride is never administered as a bolus injection because it can cause cardiac arrest. A filter is not necessary for potassium solutions. Cool compresses would constrict the blood vessel, which could possibly be more irritating to the vein.
To assure the desired results, how should the nurse instruct the client prescribed oral bisacodyl to take the medication?
- A. At bedtime
- B. With a large meal
- C. With a glass of milk
- D. On an empty stomach
Correct Answer: A
Rationale: Bisacodyl is a stimulant laxative that works by stimulating peristalsis in the colon. To ensure its effectiveness, it should be taken at bedtime to produce a bowel movement in the morning, typically 6 to 12 hours after administration. Taking it with a large meal or milk may reduce its effectiveness due to delayed gastric emptying or interaction with food. Taking it on an empty stomach may cause stomach irritation and is not necessary for its action.
The nurse caring for a client after right radical mastectomy includes which intervention in the nursing plan of care for this client?
- A. Takes blood pressures in the right arm only
- B. Draws serum laboratory samples from the right arm only
- C. Positions the client supine and flat with the right arm elevated on a pillow
- D. Checks the right posterior axilla area when assessing the surgical dressing
Correct Answer: D
Rationale: If there is drainage or bleeding from the surgical site after mastectomy, gravity will cause the drainage to seep down and soak the posterior axillary portion of the dressing first. The nurse checks this area to detect early bleeding. Blood pressure measurement, venipuncture, and intravenous sites should not involve use of the operative arm. The client should be positioned with the head in semi-Fowler's position and the arm on the operative side elevated on pillows to decrease edema.