Nokea
The nurse is caring for a client with Cushing's syndrome. Which of the following nursing actions would be of HIGHEST priority?
- A. Implement measures to prevent skin breakdown.
- B. Plan measures to prevent infections.
- C. Teach the client signs and symptoms of hyperglycemia.
- D. Instigate measures to prevent fluid overload.
Correct Answer: D
Rationale: respirations are the first priority; clients with Cushing's syndrome are prone to fluid overload and CHF due to sodium and water retention
You may also like to solve these questions
The nurse is caring for a client with a new colostomy. Which of the following client statements indicates a need for further teaching?
- A. I will change the pouch when it is about one-third full.
- B. I will empty the pouch every evening before bed.
- C. I will avoid gas-forming foods like beans and broccoli.
- D. I will check the skin around the stoma for irritation.
Correct Answer: B
Rationale: the pouch should be emptied when one-third to one-half full, not on a fixed schedule
The home care nurse instructs the wife of a client about how to perform a wet-to-dry abdominal dressing for her husband with an infected abdominal incision. The nurse should intervene in which of the following situations?
- A. The wife wets the old dressing with sterile saline before removing it.
- B. The wife covers the wound with wet, sterile 4 × 4s.
- C. The wife irrigates the wound with hydrogen peroxide using a bulb syringe.
- D. The wife uses Montgomery straps to secure the dressing.
Correct Answer: A
Rationale: contraindicated, remove dry so wound debris and necrotic tissue are removed with old dressing
The nurse is caring for a 34-year-old man admitted with low back pain. The history indicates that the patient has hemophilia A. The nurse should question which of the following orders?
- A. Ketorolac tromethamine (Toradol).
- B. Codeine phosphate (Paveral).
- C. Oxycodone terephthalate (Percodan).
- D. Hydromorphone hydrochloride (Dilaudid).
Correct Answer: C
Rationale: contraindicated for persons with bleeding disorders, contains aspirin
The nurse is caring for a 22-year-old woman who is completing the first stage of labor. The woman's husband is at her side and has been coaching her according to exercises they learned at natural childbirth classes. Suddenly the woman begins to shake and screams, 'I can't stand this anymore!' The nurse should encourage the husband to
- A. instruct his wife to use shallow respirations during the contractions.
- B. offer his wife ice chips or sips of water to distract her from the pain.
- C. stroke his wife's abdomen between contractions.
- D. review with his wife the breathing pattern needed at each stage of labor.
Correct Answer: A
Rationale: entering transition phase of first stage of labor, slow shallow breaths needed (pant breathing)
When assessing orientation to person, place, and time for an elderly hospitalized client, which of the following principles should be understood by the nurse?
- A. Short-term memory is more efficient than long-term memory.
- B. The stress of an unfamiliar environment may cause confusion.
- C. A decline in mental status is a normal part of aging.
- D. Learning ability is reduced during hospitalization of the elderly client.
Correct Answer: B
Rationale: stress of an unfamiliar situation or environment may lead to confusion in elderly clients