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The nurse is planning care for a client being admitted with bleeding esophageal varices. Vital signs are: Pulse 100; respiratory rate 22; and blood pressure 100/58. The nurse should prepare the client for which of the following? Select all that apply.
- A. Administration of intravenous Octreotide (Sandostatin).
- B. Endoscopy.
- C. Administration of a blood product.
- D. Minnesota tube insertion.
- E. Transjugular intrahepatic portosystemic shunt (TIPS).
Correct Answer: A,B,C,D
Rationale: Octreotide (A) reduces portal pressure, endoscopy (B) diagnoses and treats bleeding, blood products (C) correct hypovolemia, and a Minnesota tube (D) controls bleeding. TIPS (E) is a later intervention.
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A nurse is assessing a client with a urinary tract infection who takes an antihypertensive drug. The nurse reviews the client’s urinalysis results (see chart). The nurse should:
- A. Encourage the client to increase fl uid intake.
- B. Withhold the next dose of antihypertensive medication.
- C. Restrict the client’s sodium intake.
- D. Encourage the client to eat at least half of a banana per day
Correct Answer: A
Rationale: The client’s urine specifi c gravity is elevated. Specific gravity is a refl ection of the concentrating ability of the kidneys. This level indicates that the urine is concentrated. By increasing fluid intake, the urine will become more dilute. Antihypertensives do not make urine more concentrated unless there is a diuretic component within them. The nurse should not hold a dose of antihypertensive medication. Sodium tends to pull water with it; by restricting sodium, less water, not more, will be present. Bananas do not aid in the dilution of urine.
A client is being switched from levodopa (L-dopa) to carbidopa-levodopa (Sinemet). The nurse should monitor for which of the following possible complications during medication changes and dosage adjustment?
- A. Euphoria.
- B. Jaundice.
- C. A military fluctuation.
- D. Signs and symptoms of diabetes.
Correct Answer: B
Rationale: Jaundice may indicate hepatotoxicity, a rare but serious complication of levodopa or carbidopa-levodopa. Euphoria, motor fluctuations, and diabetes are not primary concerns during this switch.
Thirty-two children are brought to the emergency department after a school bus accident. Two children were killed along with the three people in the car that caused the crash. Before the victims arrive, in addition to ensuring that the hospital staff are prepared for the emergency, which step should the nurse anticipate carrying out?
- A. Calling the nearest crisis response team.
- B. Alerting the news media.
- C. Notifying the hospital volunteer office.
- D. Calling the school to inform teachers of the accident.
Correct Answer: A
Rationale: A crisis response team is essential to provide psychological support to victims, families, and staff following a traumatic event like a school bus accident with fatalities.
A client has been admitted with draining foot lesions. The nurse should do which of the following? Select all that apply.
- A. Place the client in a room with negative air pressure.
- B. Admit the client to a semi-private room.
- C. Admit the client to a private room.
- D. Post a "contact isolation" sign on the door.
- E. Wear a protective gown when in the client's room.
- F. Wear latex-free gloves when providing direct care.
Correct Answer: C,D,E,F
Rationale: Draining lesions require contact precautions, including a private room, isolation signage, gowns, and gloves (latex-free to avoid allergies). Negative pressure is for airborne pathogens.
A priority nursing diagnosis for an adult female who has pruritus and is continuously scratching the affected areas and demonstrates agitation and anxiety regarding the itching sensation would be:
- A. Risk for infection related to pruritus.
- B. Ineffective health maintenance related to lack of knowledge of the disease process.
- C. Unsporced skin integrity related to dehydration from the treatment medications.
- D. Social isolation related to poor self-image.
Correct Answer: A
Rationale: Scratching due to pruritus increases the risk of skin breakdown and infection, making this the priority nursing diagnosis.