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The nurse is performing a physical assessment of a client with a history of smoking and notes a barrel chest. Which action is most important for the nurse to take next?
- A. Assess the client's oxygen saturation level
- B. Teach the client pursed-lip breathing techniques
- C. Determine the client's history of lung disease
- D. Obtain an arterial blood gas sample
Correct Answer: A
Rationale: Corrected Rationale: Assessing the client's oxygen saturation level is crucial when a nurse identifies a barrel chest. A barrel chest is often associated with chronic obstructive pulmonary disease (COPD), which can lead to impaired gas exchange and decreased oxygen saturation. Monitoring the oxygen saturation level will provide immediate information on the client's respiratory status. Teaching pursed-lip breathing techniques, determining lung disease history, and obtaining arterial blood gas samples are important interventions but assessing oxygen saturation takes precedence in this scenario due to its direct impact on the client's respiratory function.
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A female client on the mental health unit tells the nurse that her roommate is sitting on the bathroom floor with superficial cuts on her wrists. The nurse cleans and assesses the client's wrists and asks what happened. She doesn't respond. What should the nurse do next?
- A. Find supplies to put a dressing on the client's wrists
- B. Take the client to a room for supervision by staff
- C. Call the healthcare provider to report the client's behavior
- D. Go find a staff member to stay in the room with the client
Correct Answer: B
Rationale: In this situation, the nurse should prioritize the safety of the client. Taking the client to a room for supervision by staff is crucial to ensure immediate safety and further assessment of the client's condition. While cleaning and assessing the client's wrists are important, ensuring ongoing safety and monitoring by staff is the priority. Calling the healthcare provider at this moment may cause delays in providing immediate assistance. Finding supplies to put a dressing on the client's wrists can wait until the client is in a safe environment. Therefore, option B is the best course of action to address the client's safety needs promptly.
The nurse is caring for a client who is receiving morphine sulfate via a patient-controlled analgesia (PCA) pump. Which action is most important for the nurse to implement?
- A. Monitor the client's respiratory status
- B. Teach the client how to use the PCA pump
- C. Evaluate the client's pain level
- D. Assess the client's pain level
Correct Answer: A
Rationale: The correct answer is to monitor the client's respiratory status. When administering opioids like morphine sulfate via a PCA pump, it is crucial to closely monitor the client's respiratory status to detect signs of respiratory depression early. This is important for ensuring the client's safety while receiving pain management. Choices B, C, and D are incorrect because while teaching the client to use the PCA pump and assessing or evaluating their pain level are essential aspects of care, monitoring respiratory status takes precedence due to the potential risks associated with opioid use.
A client who had an intraosseous (IO) cannula placed by the healthcare provider for emergent fluid resuscitation is complaining of severe pain and numbness below the IO site. The skin around the site is pale and edematous. What action should the nurse take first?
- A. Discontinue the IO infusion
- B. Administer an analgesic via the IO site
- C. Elevate the extremity with the IO site
- D. Notify the healthcare provider
Correct Answer: A
Rationale: In this scenario, the client's symptoms of severe pain, numbness, pale skin, and edema below the IO site raise concerns for complications like compartment syndrome or extravasation. The priority action for the nurse is to discontinue the IO infusion to prevent further harm to the client. Administering an analgesic via the IO site or elevating the extremity with the IO site may delay addressing the potential serious complications. While notifying the healthcare provider is important, the immediate action to ensure client safety is to stop the infusion.
A client with a small bowel obstruction is experiencing frequent vomiting. Which instructions are most important for the nurse to provide to the unlicensed assistive personnel (UAP) who is completing morning care for this client?
- A. Maintain a quiet environment
- B. Ensure the linens are clean and dry
- C. Place an air deodorizer in the room
- D. Measure all emesis accurately
Correct Answer: D
Rationale: The correct answer is D, 'Measure all emesis accurately.' When a client with a small bowel obstruction is experiencing frequent vomiting, measuring emesis accurately is crucial for monitoring fluid balance and preventing dehydration. Choice A, 'Maintain a quiet environment,' while important for patient comfort, is not as critical as accurately measuring emesis. Choices B and C, 'Ensure the linens are clean and dry' and 'Place an air deodorizer in the room,' focus on environmental factors that, although helpful, are not as essential as monitoring the client's fluid balance in this situation.
The nurse working in an emergency center collects physical evidence 6 hours following a reported sexual assault. After placing the samples in sealed containers, which action is most important for the nurse to implement?
- A. Maintain possession of the evidence collection kit at all times until submitted to law enforcement
- B. Provide discharge instructions for prophylactic antibiotics, pregnancy, and HIV prevention medication
- C. Document the characteristics of the various sites of sample collection
- D. Assist the client with toileting, hygiene, and dressing with clean clothes
Correct Answer: A
Rationale: Maintaining possession of the evidence collection kit at all times until submitted to law enforcement is crucial to ensure the integrity of the chain of custody. This step helps prevent tampering or contamination of the evidence, which is vital for the legal process. Providing discharge instructions for medications, documenting sample characteristics, and assisting the client with personal care are important aspects of care but not the immediate priority when handling forensic evidence in a sexual assault case.