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The nurse is caring for a client who reports a sudden, severe headache, and facial numbness. The nurse asks the client to smile and observes an uneven smile with facial droop to the right side and a hand grasp strength that is weaker on the right than the left. The client denies a recent history of headaches or trauma. Which intervention should the nurse perform in the immediate management of the client?
- A. Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.
- B. Administer aspirin to prevent further clot formation and platelet clumping.
- C. Verify prescribed laboratory tests include prothrombin time and platelet count.
- D. Maintain elevated positioning of the dependent joints on affected side.
Correct Answer: A
Rationale: Starting two large bore IV catheters and reviewing criteria for IV fibrinolytic therapy is essential for managing a suspected stroke, enabling time-sensitive interventions.
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The nurse is preparing a client for surgery who was admitted from the emergency department following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site. During the preoperative assessment, the nurse determines that the client currently receives heparin sodium 5,000 units SUBQ daily. Which nursing action is a priority?
- A. Have the client sign the surgical and transfusion permits.
- B. Notify the healthcare provider of the client's medication history.
- C. Ensure that the potential for bleeding is explained to the client.
- D. Observe the heparin injections sites for signs of bruising.
Correct Answer: B
Rationale: Notifying the healthcare provider of the client's heparin use is crucial to ensure appropriate perioperative management and prevent excessive bleeding during surgery.
A client receives a prescription for 3 liters of lactated Ringer's IV to infuse over 24 hours. How many mL/hr should the nurse program the infusion pump?
- A. 125
Correct Answer: A
Rationale: To calculate: 3000 mL / 24 hr = 125 mL/hr. The nurse should program the infusion pump to deliver 125 mL/hr.
The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. Which action should the nurse take?
- A. Collect the blood sample.
- B. Select another finger.
- C. Apply pressure to the site.
- D. Assess radial pulse volume.
Correct Answer: B
Rationale: Selecting another finger ensures an accurate blood sample and minimizes discomfort, as a reddened and engorged fingertip may lead to inaccurate readings.
A client who has small cell carcinoma of the lung is admitted with symptoms of syndrome of inappropriate antidiuretic hormone (SIADH). As the client's serum sodium level increases from 120 mEq/L to 125 mEq/L, which intervention should the nurse implement?
- A. Assess for increasing fluid volume overload.
- B. Withhold next scheduled dose of treatment.
- C. Increase neurologic checks to every 2 hours.
- D. Maintain the prescribed fluid restriction.
Correct Answer: D
Rationale: Maintaining the prescribed fluid restriction is essential to prevent further dilutional hyponatremia and to help normalize the serum sodium level gradually.
History and Physical
A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue inhaler three times, but he just couldn't catch his breath.
The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.
Click to highlight the two pieces of key subjective data which indicate the client is in need of health interventions.
- A. The client reports using a rescue inhaler three times, but he just couldn't catch his breath.
- B. Symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous.
Correct Answer: A,B
Rationale: The client's report of using a rescue inhaler multiple times without relief and the exacerbation of symptoms when outdoors and during exercise suggest that the client's asthma is not well-controlled, warranting immediate medical attention.