Nokea
The nurse is caring for a client who is 4 hours post-operative from abdominal surgery. The client is complaining of severe pain. What is the nurse's first action?
- A. Reassess the pain and its characteristics
- B. Administer prescribed pain medication
- C. Notify the surgeon
- D. Encourage the use of relaxation techniques
Correct Answer: A
Rationale: The correct first action for the nurse to take when a post-operative client complains of severe pain is to reassess the pain and its characteristics. Reassessment is crucial to understand the nature and intensity of the pain, which will guide the nurse in providing appropriate interventions. Administering pain medication may be necessary but should only be done after reassessment to ensure the right medication and dose are given. Notifying the surgeon may be required in certain situations, but reassessment of pain should precede this action. Encouraging relaxation techniques is not the priority when a client is experiencing severe pain post-operatively.
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When observing a newly admitted elderly client with dementia resisting care, what approach should the nurse take to facilitate cooperation?
- A. Use short, simple sentences and maintain a calm demeanor
- B. Involve family members to provide reassurance
- C. Offer choices to empower the client
- D. All of the above
Correct Answer: D
Rationale: When dealing with a newly admitted elderly client with dementia who is resistant to care, it is crucial to employ multiple strategies to facilitate cooperation. Using short, simple sentences and maintaining a calm demeanor can help the client better understand instructions and reduce agitation. Involving family members can provide comfort and reassurance to the client, potentially decreasing resistance. Offering choices allows the client to feel a sense of control and autonomy in their care, which can increase cooperation and reduce challenging behaviors. Therefore, a combination of clear communication, family involvement, and providing choices is essential to effectively engage and care for a client with dementia. Choices A, B, and C all play crucial roles in addressing the needs of the client, making 'All of the above' the correct answer.
A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with shortness of breath. What is the priority nursing intervention?
- A. Administer a high-flow oxygen mask.
- B. Position the client in a high-Fowler's position.
- C. Provide a high-carbohydrate diet.
- D. Encourage the client to cough and deep breathe.
Correct Answer: B
Rationale: The priority nursing intervention for a client with COPD experiencing shortness of breath is to position the client in a high-Fowler's position. This position helps improve lung expansion and breathing by reducing respiratory effort. Administering a high-flow oxygen mask (Choice A) may be necessary but is not the priority intervention. Providing a high-carbohydrate diet (Choice C) is not directly related to managing acute shortness of breath in COPD. Encouraging the client to cough and deep breathe (Choice D) is helpful for airway clearance but is not the priority intervention when the client is in distress with acute shortness of breath.
A client with a diagnosis of tuberculosis (TB) is being discharged home. Which instruction is most important for the nurse to provide?
- A. Avoid close contact with others until treatment is complete.
- B. Take all prescribed medications as directed.
- C. Schedule a follow-up appointment with the healthcare provider.
- D. Wear a mask when in public places.
Correct Answer: B
Rationale: The most important instruction for a client with tuberculosis (TB) is to take all prescribed medications as directed. This is crucial to prevent the development of drug-resistant TB. While avoiding close contact with others until treatment is complete (Choice A) is important to prevent the spread of TB, ensuring the client completes the prescribed medication regimen is the priority. Scheduling a follow-up appointment (Choice C) is important for monitoring but not as critical as medication adherence. Wearing a mask in public places (Choice D) can help reduce the spread of TB but is not as essential as taking medications as prescribed.
The client has chronic renal failure. What dietary modification is most important for this client?
- A. Increase protein intake
- B. Limit potassium-rich foods
- C. Increase sodium intake
- D. Encourage dairy products
Correct Answer: B
Rationale: Limiting potassium-rich foods is crucial in chronic renal failure to prevent hyperkalemia, which can lead to cardiac complications. Excessive protein intake can increase the workload on the kidneys and may result in the accumulation of uremic toxins. Increasing sodium intake is generally discouraged in chronic renal failure due to its association with hypertension and fluid retention. Encouraging dairy products may not be suitable for all clients with chronic renal failure, as they are a significant source of phosphorus, which needs to be limited in renal failure to prevent mineral imbalances.
A client is admitted with diabetic ketoacidosis. What is the most critical treatment to initiate?
- A. Administer sodium bicarbonate IV
- B. Start an insulin drip
- C. Monitor glucose and ketone levels
- D. Provide oral hydration
Correct Answer: B
Rationale: In the case of diabetic ketoacidosis, the most critical treatment to initiate is starting an insulin drip. Insulin therapy is crucial for reducing blood glucose levels by promoting glucose uptake in cells and inhibiting the production of ketones. Administering sodium bicarbonate IV is generally not recommended as it may lower the pH further and potentially worsen the condition. While monitoring glucose and ketone levels is important for assessing the response to treatment, initiating insulin therapy takes precedence. Providing oral hydration alone is insufficient to manage the metabolic derangements seen in diabetic ketoacidosis.