Nokea
The nurse is caring for a laboring 22-year-old primigravida following administration of regional anesthesia. In planning care for this client, what nursing intervention has the highest priority?
- A. Raising the side rails and placing the call bell within reach
- B. Teaching the client how to push effectively to decrease the length of the second stage of labor
- C. Timing and recording uterine contractions
- D. Positioning the client for proper distribution of anesthesia
Correct Answer: A
Rationale: The correct answer is A because raising the side rails and placing the call bell within reach ensures the safety and immediate accessibility of the client, which is the highest priority in nursing care. This intervention helps prevent falls or other accidents and allows the client to call for assistance if needed.
Choice B is incorrect because teaching pushing techniques is important but not the highest priority at this moment. Choice C, timing and recording uterine contractions, is also important but not the highest priority compared to ensuring the client's safety. Choice D, positioning for anesthesia distribution, is relevant but not as critical as ensuring immediate access to assistance in case of emergency.
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The nurse is caring for a 10-year-old diagnosed with acute glomerulonephritis. Which outcome is the priority for this child?
- A. Activity tolerance as evidenced by appropriate age-level activities being performed
- B. Absence of skin breakdown as evidenced by intact skin and absence of redness
- C. Maintaining adequate nutritional status as evidenced by stable weight without gain or loss
- D. Maintaining fluid balance as evidenced by a urine output of 1 to 2 ml/kg/hr
Correct Answer: D
Rationale: The correct answer is D. In acute glomerulonephritis, the kidneys are inflamed, affecting fluid balance. Monitoring urine output of 1 to 2 ml/kg/hr is crucial to assess kidney function and prevent fluid overload or dehydration. This is the priority outcome as it directly reflects kidney function and overall fluid balance.
A: Activity tolerance is important but not the priority in acute glomerulonephritis.
B: Absence of skin breakdown is important for overall health but not directly related to the condition.
C: Nutritional status is important, but fluid balance takes precedence in managing acute glomerulonephritis.
In summary, maintaining fluid balance is crucial in managing acute glomerulonephritis as it directly reflects kidney function, while the other options are important but not the priority in this scenario.
What assessment technique should the nurse use to monitor a client for a common untoward effect of phenytoin (Dilantin)?
- A. Bladder palpation
- B. Inspection of the mouth
- C. Blood glucose monitoring
- D. Auscultation of breath sounds
Correct Answer: B
Rationale: The correct answer is B: Inspection of the mouth. Phenytoin can cause gingival hyperplasia as a common untoward effect. By inspecting the mouth regularly, the nurse can assess for signs of this side effect such as swollen or bleeding gums. Bladder palpation (A) is not relevant to monitoring phenytoin side effects. Blood glucose monitoring (C) is not typically associated with phenytoin use. Auscultation of breath sounds (D) is not directly related to monitoring for phenytoin side effects.
A nurse is planning care for a client who is newly diagnosed with diabetes mellitus. Which instruction should the nurse include in this client¢â‚¬â„¢s teaching plan?
- A. Avoid all forms of sugar
- B. Check blood glucose levels once a week
- C. Rotate insulin injection sites
- D. Monitor urine ketone levels
Correct Answer: C
Rationale: The correct answer is C: Rotate insulin injection sites. This instruction is crucial to prevent lipohypertrophy, which can lead to inconsistent insulin absorption. By rotating injection sites, the client ensures proper insulin absorption and prevents complications. Checking blood glucose levels once a week (B) is not frequent enough for proper diabetes management. Avoiding all forms of sugar (A) is an outdated approach, as moderation is key. Monitoring urine ketone levels (D) is not as reliable as blood ketone testing for assessing diabetic ketoacidosis risk.
In preparing to administer a scheduled dose of intravenous furosemide (Lasix) to a client with heart failure, the nurse notes that the client's B-Type Naturetic peptide (BNP) is elevated. What action should the nurse take?
- A. Measure the client's oxygen saturation before taking further action
- B. Administer a PRN dose of nitroglycerin (Nitrostat)
- C. Administer the dose of furosemide as scheduled
- D. Hold the dose of furosemide until contacting the healthcare provider
Correct Answer: C
Rationale: The correct action is to administer the dose of furosemide as scheduled (Choice C) because an elevated BNP level indicates increased fluid volume and pressure in the heart. Furosemide is a diuretic that helps reduce fluid overload in heart failure patients, which can alleviate symptoms and improve cardiac function. Holding the dose (Choice D) could delay necessary treatment, potentially worsening the patient's condition. Measuring oxygen saturation (Choice A) is important but not the immediate priority in this situation. Administering nitroglycerin (Choice B) is not appropriate as it is used for chest pain related to angina, not for treating elevated BNP levels in heart failure.
A client with an electrical burn on the forearm asks the nurse why there is no feeling of pain from the burn. During the dressing change, the nurse determines that the burn is dry, waxy, and white. What information should the nurse provide this client?
- A. The depth of tissue destruction is minor
- B. Pain is interrupted due to nerve compression
- C. The full thickness burn has destroyed the nerves
- D. Second-degree burns are not usually painful
Correct Answer: C
Rationale: The correct answer is C because full-thickness burns destroy nerve endings, resulting in the absence of pain sensation. The dry, waxy, and white appearance indicates tissue destruction extending through the epidermis and dermis. Choices A and D are incorrect because dry, waxy, and white appearance signifies a deeper burn, not a minor or superficial burn, and second-degree burns typically involve pain sensation. Choice B is incorrect as nerve compression does not explain the lack of pain sensation in a full-thickness burn.