Nokea
The nurse is caring for a client with increased intracranial pressure (ICP). Which position should the nurse avoid?
- A. Keeping the head of the bed elevated at 30 degrees
- B. Positioning the client in the prone position
- C. Placing the client in a lateral recumbent position
- D. Elevating the client's legs
Correct Answer: B
Rationale: The correct answer is B: Positioning the client in the prone position. Placing the client in the prone position should be avoided in a client with increased intracranial pressure (ICP) as it can further raise ICP. The prone position can hinder venous return and increase pressure within the cranial vault, potentially worsening the client's condition. Keeping the head of the bed elevated at 30 degrees helps promote venous drainage and reduce ICP. Placing the client in a lateral recumbent position can also assist in reducing ICP by optimizing cerebral perfusion. Elevating the client's legs can help improve venous return and maintain adequate cerebral blood flow, making it a suitable positioning intervention for managing increased ICP.
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A client with a history of hypertension is prescribed hydrochlorothiazide (HCTZ). Which adverse effect should the nurse monitor for?
- A. Hyperkalemia
- B. Hyponatremia
- C. Bradycardia
- D. Hyperglycemia
Correct Answer: B
Rationale: The correct answer is 'B. Hyponatremia.' Hydrochlorothiazide can lead to electrolyte imbalances, such as hyponatremia, due to its diuretic effect. This potential adverse effect should be closely monitored in patients taking HCTZ. Choice A, hyperkalemia, is less likely to occur with HCTZ as it tends to cause hypokalemia. Choice C, bradycardia, is not a common adverse effect of HCTZ. Choice D, hyperglycemia, is also less commonly associated with HCTZ use compared to hyponatremia.
A client who fell 20 feet from the roof of his home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the intensive care unit (ICU). The nurse observes that the suction control chamber is bubbling at the -10 cm H20 mark, with fluctuation in the water seal, and over the past hour, 75 mL of bright red blood is measured in the collection chamber. Which intervention should the nurse implement?
- A. Increase wall suction to eliminate fluctuation in the water seal.
- B. Give blood from the collection chamber as autotransfusion.
- C. Add sterile water to the suction control chamber.
- D. Manipulate blood in tubing to drain into chamber.
Correct Answer: C
Rationale: The correct intervention for the nurse to implement is to add sterile water to the suction control chamber. This action helps maintain the proper functioning of the chest tube system by regulating the negative pressure. Increasing wall suction is not recommended as it could lead to excessive negative pressure. Giving blood from the collection chamber as autotransfusion is inappropriate and poses a risk of complications such as air embolism. Manipulating blood in the tubing is also unsafe as it could introduce air into the system, increasing the risk of complications for the client.
A client is prescribed metformin for the management of type 2 diabetes. What is the primary action of this medication?
- A. Stimulates insulin secretion from the pancreas.
- B. Increases insulin sensitivity in various tissues.
- C. Decreases hepatic glucose production.
- D. Delays absorption of glucose from the intestines.
Correct Answer: C
Rationale: The correct answer is C: Decreases hepatic glucose production. Metformin primarily works by reducing the production of glucose in the liver (hepatic glucose production) and by improving insulin sensitivity in various tissues. Choice A is incorrect as metformin does not stimulate insulin secretion from the pancreas. Choice B is incorrect as metformin increases insulin sensitivity in various tissues, not just muscle cells. Choice D is incorrect as metformin does not delay glucose absorption from the intestines.
What should the nurse prioritize when providing discharge instructions to a client with a new colostomy?
- A. Skin care around the stoma site
- B. The schedule for colostomy bag replacement
- C. Techniques for odor control
- D. Dietary modifications
Correct Answer: A
Rationale: Correct answer: Skin care around the stoma site. Proper skin care around the stoma site is crucial for preventing skin irritation and infection, which are common issues for patients with new colostomies. While the schedule for colostomy bag replacement (Option B) is important, it is not the priority during initial discharge instructions. Techniques for odor control (Option C) are relevant but secondary to skin care for a new colostomy. Dietary modifications (Option D) may be discussed later but are not the priority at this stage.
The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who is experiencing shortness of breath. What is the priority nursing intervention?
- A. Administer bronchodilator therapy as prescribed
- B. Encourage deep breathing and coughing exercises
- C. Position the client in a high-Fowler's position
- D. Increase the oxygen flow rate
Correct Answer: C
Rationale: The priority nursing intervention for a client with COPD experiencing shortness of breath is to position the client in a high-Fowler's position. This position helps improve lung expansion and ease breathing in COPD patients. While administering bronchodilator therapy as prescribed (Choice A) is important, it is not the priority in this scenario. Encouraging deep breathing and coughing exercises (Choice B) can be beneficial but do not take precedence over positioning for improved respiratory function. Increasing the oxygen flow rate (Choice D) can be considered after the initial positioning to relieve respiratory distress, making it a later intervention.