Nokea
The nurse is caring for a client with fluid overload. The most reliable indicator of fluid volume status is
- A. Body weight
- B. Intake and output
- C. Daily weight
- D. Skin turgor
Correct Answer: C
Rationale: Daily weight is the most reliable indicator of fluid volume status as it reflects changes in body fluid balance accurately. Body weight alone can fluctuate due to various factors, including food intake and bowel movements, which may not accurately represent fluid status. Intake and output provide information on fluid balance over time but may not reflect immediate changes. Skin turgor is a physical assessment finding that indicates hydration status, not overall fluid volume status.
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A 5-week-old infant with hypertrophic pyloric stenosis has developed projectile vomiting over the last two weeks. Which intervention should the nurse plan to implement?
- A. Instruct the mother to give sugar water only.
- B. Offer the infant oral rehydration every 2 hours.
- C. Provide Pedialyte feedings via nasogastric tube.
- D. Maintain intravenous fluid therapy.
Correct Answer: D
Rationale: The correct intervention for a 5-week-old infant with hypertrophic pyloric stenosis presenting with projectile vomiting is to maintain intravenous fluid therapy. This is essential to maintain hydration before surgery. Instructing the mother to give sugar water only (Choice A) is inadequate and does not address the need for proper hydration. Offering oral rehydration every 2 hours (Choice B) may not be effective in cases of severe vomiting and could lead to further fluid loss. Providing Pedialyte feedings via nasogastric tube (Choice C) is an option, but in severe cases, intravenous fluid therapy is more effective in ensuring hydration and electrolyte balance.
A client is receiving a blood transfusion and develops chills and back pain. What is the nurse's first action?
- A. Stop the transfusion and notify the healthcare provider.
- B. Monitor the client's vital signs every 15 minutes.
- C. Administer a PRN dose of diphenhydramine.
- D. Prepare to administer an antihistamine.
Correct Answer: A
Rationale: The correct first action for the nurse is to stop the transfusion and notify the healthcare provider. These symptoms suggest a transfusion reaction, and stopping the transfusion is crucial to prevent further complications. Notifying the healthcare provider ensures timely intervention and appropriate management for the client's condition. Monitoring vital signs, administering diphenhydramine, or preparing to administer an antihistamine can be considered after stopping the transfusion and seeking guidance from the healthcare provider. However, the immediate priority is to halt the transfusion and inform the provider.
A client with adrenal crisis has a temperature of 102°F, heart rate of 138 bpm, and blood pressure of 80/60 mmHg. Which action should the nurse implement first?
- A. Obtain an analgesic prescription.
- B. Infuse intravenous fluid bolus.
- C. Administer PRN oral antipyretic.
- D. Cover the client with a cooling blanket.
Correct Answer: B
Rationale: In a client with adrenal crisis presenting with a high temperature, tachycardia, and hypotension, the priority action for the nurse to implement first is to infuse an intravenous fluid bolus. This intervention aims to address the hypotension by increasing the circulating volume and improving perfusion. Obtaining an analgesic prescription (Choice A) is not the priority in this situation. Administering an oral antipyretic (Choice C) may help reduce the fever but does not address the primary issue of hypotension. Covering the client with a cooling blanket (Choice D) may help with temperature control but does not address the hemodynamic instability caused by the adrenal crisis.
In monitoring tissue perfusion in a client following an above the knee amputation (AKA), which action should the nurse include in the plan of care?
- A. Evaluate closest proximal pulse.
- B. Note amount and color of wound drainage.
- C. Observe for swelling around the stump.
- D. Assess skin elasticity of the stump.
Correct Answer: A
Rationale: After an amputation, monitoring the pulse closest to the stump is crucial in evaluating tissue perfusion and the overall health of the limb. Swelling and changes in perfusion can indicate complications such as blood clots or infection. Assessing the proximal pulse helps the nurse ensure adequate blood flow to the remaining limb, thereby preventing further complications. Choices B, C, and D are less directly related to monitoring tissue perfusion in this scenario and are more focused on wound healing and stump care.
The nurse is caring for a seated client experiencing a tonic-clonic seizure. Which actions should the nurse implement?
- A. Place a padded tongue depressor in the client's mouth
- B. Restrain the client and attempt to stop the seizure
- C. Begin CPR immediately
- D. Loosen restrictive clothing and ease the client to the floor
Correct Answer: D
Rationale: During a tonic-clonic seizure, the nurse should loosen restrictive clothing to prevent injury and ease the client to the floor to ensure safety. Placing any object, such as a tongue depressor, in the client's mouth is contraindicated as it may cause harm. Restraint should not be used as it can lead to injury. Beginning CPR is not indicated during a seizure unless the client experiences cardiac arrest, which is a rare complication of seizures.