Nokea
The nurse is caring for a client with a history of spinal cord injury who is admitted with a urinary tract infection. Which of the following interventions should the nurse implement?
- A. Encourage the client to limit fluid intake.
- B. Administer antibiotics as ordered.
- C. Insert an indwelling catheter.
- D. Restrict the client to bed rest.
Correct Answer: B
Rationale: antibiotics are the primary treatment for a urinary tract infection
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A client is being discharged on Coumadin after hospitalization for a deep vein thrombosis. The nurse recognizes that which food would be restricted while the client is on this medication?
- A. Lettuce
- B. Apples
- C. Potatoes
- D. Macaroni
Correct Answer: A
Rationale: Lettuce, especially leafy greens, is high in vitamin K, which can antagonize Coumadin's anticoagulant effect, requiring dietary restriction or monitoring.
The nurse is caring for a 42-year-old client who has a do not resuscitate (DNR) order on the chart. The client tells the nurse, 'I've changed my mind about the DNR. I would like to cancel that and be given whatever care is needed to keep me alive.' Which response by the nurse is correct?
- A. I will notify your health care provider right away.'
- B. I'm glad to hear this. You shouldn't be a DNR at your age.'
- C. Let me call your family and tell them you have changed your mind.'
- D. You cannot change a DNR once it's on your chart. It is a legal document.'
Correct Answer: A
Rationale: A DNR can be revoked by the client at any time. Notifying the provider ensures the change is documented and followed.
The nurse is caring for a female client following the removal of the parathyroid glands. The client complains of a 'pins and needles' sensation and difficulty swallowing lunch. The nurse would expect which laboratory value to be abnormal?
- A. calcium
- B. potassium
- C. magnesium
- D. blood glucose
Correct Answer: A
Rationale: Parathyroidectomy can cause hypocalcemia, leading to paresthesia ('pins and needles') and dysphagia due to muscle dysfunction.
A 5-month-old is diagnosed with atopic dermatitis. Nursing interventions will focus on:
- A. Preventing infection
- B. Administering antipyretics
- C. Keeping the skin free of moisture
- D. Limiting oral fluid intake
Correct Answer: A
Rationale: Atopic dermatitis involves inflamed skin prone to infection, so preventing infection through gentle skin care and monitoring is a priority.
The nurse is caring for a 27-year-old client in active labor. After reviewing the fetal heart tone strip shown, the nurse should take which action first?
- A. reposition the client
- B. draw a potassium level
- C. notify the health care provider
- D. prepare the client for a cesarean section
Correct Answer: A
Rationale: Repositioning the client is the first step to improve fetal oxygenation if the fetal heart tone strip shows distress, as it is non-invasive and may resolve the issue.