Nokea
The nurse is caring for a client with chronic renal failure who is receiving dialysis. The client reports muscle cramps and tingling in the hands. Which laboratory result should the nurse monitor to identify the cause of these symptoms?
- A. Sodium
- B. Calcium
- C. Phosphate
- D. Potassium
Correct Answer: B
Rationale: Muscle cramps and tingling in clients with chronic renal failure are often associated with hypocalcemia. Monitoring calcium levels is crucial to identify imbalances and manage symptoms appropriately. Sodium, phosphate, and potassium levels are important in renal failure but are not directly related to the symptoms of muscle cramps and tingling reported by the client.
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A client with antisocial personality disorder repeatedly requests a specific nurse be assigned to him and is belligerent when another nurse is assigned. What action should the charge nurse implement?
- A. Remind the client that nurse assignments are not based on patient requests
- B. Assign the nurse requested by the client to avoid further conflict
- C. Tell the client that he can request a different nurse if unhappy
- D. Explain the situation calmly and reinforce the rules regarding nurse assignments
Correct Answer: A
Rationale: The correct action for the charge nurse to implement is to remind the client that nurse assignments are not based on patient requests. In this situation, it is essential to establish boundaries and communicate that nurse assignments are made based on clinical decisions, not patient preferences. Option B is incorrect because it compromises the principle of fairness in nurse assignments. Option C is incorrect as it encourages the client's behavior by allowing him to request a different nurse based on personal preferences. Option D is also incorrect as it does not address the issue of patient manipulation and reinforces inappropriate behavior.
A client with a prescription for DNR begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement?
- A. Inform the healthcare provider
- B. Determine the client's need for pain medication
- C. Begin comfort measures
- D. Ensure all life-saving equipment is removed
Correct Answer: B
Rationale: The correct priority action for the nurse to implement in this scenario is to determine the client's need for pain medication. Ensuring that the client is comfortable and free from pain is crucial in end-of-life care, especially for a client with a Do Not Resuscitate (DNR) order. This action prioritizes the client's comfort and dignity in their final moments. While informing the healthcare provider and beginning comfort measures are important aspects of care, pain management takes precedence as the immediate priority. Removing life-saving equipment is not appropriate at this stage as it goes against the client's wishes stated in the DNR order.
A client with pancreatitis reports severe pain after eating fatty foods. What intervention should the nurse implement?
- A. Encourage the client to eat small, low-fat meals.
- B. Administer antispasmodic medication as prescribed.
- C. Instruct the client to avoid eating until the pain subsides.
- D. Increase the client's intake of high-protein foods.
Correct Answer: B
Rationale: In pancreatitis, pain after consuming fatty foods is common due to increased pancreatic stimulation. Administering antispasmodics is the appropriate intervention as it can help reduce the pain by decreasing pancreatic enzyme secretion. Encouraging the client to eat small, low-fat meals (Choice A) is beneficial in managing pancreatitis symptoms but does not directly address the acute pain. Instructing the client to avoid eating until the pain subsides (Choice C) may lead to nutritional deficiencies and is not the best approach. Increasing high-protein foods intake (Choice D) is not recommended as it can put additional strain on the pancreas.
A client with lung cancer is admitted to palliative care. What is the nurse's priority assessment?
- A. Monitor respiratory status and oxygenation.
- B. Evaluate the client's mental status and cognition.
- C. Check the client's pain level and provide comfort.
- D. Assess the client's nutritional status and appetite.
Correct Answer: A
Rationale: Correct Answer: Monitoring respiratory status and oxygenation is crucial in clients with lung cancer, as metastasis to the lungs or pleural effusion can compromise breathing. This assessment helps in early identification of respiratory distress and the need for interventions to maintain adequate oxygenation. Choice B is important but not the priority in this situation. Evaluating mental status and cognition should follow after ensuring the client's physiological needs are met. Choice C, checking pain level and providing comfort, is essential but secondary to assessing respiratory status. Choice D, assessing nutritional status and appetite, is also important but not the priority when the client's breathing is at risk.
A client is receiving a blood transfusion and develops a fever. What is the nurse's first action?
- A. Administer an antipyretic as prescribed.
- B. Stop the transfusion and notify the healthcare provider.
- C. Slow the rate of the transfusion.
- D. Continue the transfusion and reassess in 15 minutes.
Correct Answer: B
Rationale: The correct first action when a client receiving a blood transfusion develops a fever is to stop the transfusion and notify the healthcare provider. This is crucial to prevent further reactions and ensure prompt intervention. Administering an antipyretic (Choice A) may mask symptoms and delay appropriate treatment. Slowing the rate of the transfusion (Choice C) might not address the underlying cause of the fever. Continuing the transfusion and reassessing in 15 minutes (Choice D) could worsen the client's condition if there is a severe reaction occurring.