Nokea
The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the start of the procedure?
- A. Verbalizes a fear of being in a confined space.
- B. Drank a glass of water in the past 2 hours.
- C. Reports left chest wall pain prior to admission.
- D. Experiences facial swelling after eating crab
Correct Answer: C
Rationale: The correct answer is C. Left chest wall pain could indicate ongoing cardiac issues or instability, which needs to be assessed before proceeding with the procedure. This pain could be related to the heart and may suggest a potential risk during the angioplasty. Options A, B, and D do not directly relate to cardiac complications during the procedure, making them less urgent for immediate assessment. Fear of confined spaces, drinking water, and facial swelling after eating crab are not immediate risks to the client's safety in the context of a cardiac catheterization procedure.
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After learning that she has terminal pancreatic cancer, a female client becomes very angry and says to the nurse, 'God has abandoned me. What did I do to deserve this?' Based on this response, the nurse decides to include which nursing problem in the client's plan of care?
- A. Ineffective coping
- B. Spiritual distress
- C. Acute pain
- D. Complicated grieving
Correct Answer: B
Rationale: The client's expression of feeling abandoned by God indicates spiritual distress, which is a significant issue that needs to be addressed in the plan of care. The individual is questioning their faith and seeking answers in a higher power, which aligns with spiritual distress. Choices A, C, and D are not as directly related to the client's current emotional and spiritual struggle. Ineffective coping may be a consequence of spiritual distress, acute pain is not the primary concern in this scenario, and complicated grieving is premature as the client is still processing the diagnosis and seeking meaning.
The nurse administers an oral antiviral to a client with shingles. Which finding is most important for the nurse to report to the healthcare provider?
- A. Decreased white blood cell count
- B. Pruritus and muscle aches
- C. Elevated liver function tests
- D. Vomiting and diarrhea
Correct Answer: C
Rationale: The correct answer is C: Elevated liver function tests. When administering antivirals, especially orally, monitoring liver function tests is crucial as it may indicate liver toxicity. This finding should be reported promptly to the healthcare provider to prevent further complications. Choice A, decreased white blood cell count, may be expected with certain antivirals but is not the most critical finding in this scenario. Pruritus and muscle aches (choice B) are common side effects of antivirals and do not require immediate reporting. Vomiting and diarrhea (choice D) are also common side effects that may not be as concerning as elevated liver function tests.
An adult male is admitted to the psychiatric unit from the emergency department because he is in the manic disorder. He has lost 10 pounds in the last two weeks and has not bathed in a week because he has been "trying to start a new business" and is "too busy to eat." He is alert and oriented to time, place and person, but not situation. Which nursing diagnosis has the greatest priority?
- A. Self-care deficit
- B. Disturbed sleep pattern
- C. Disturbed thought processes
- D. Imbalanced nutrition
Correct Answer: D
Rationale: Imbalanced nutrition is the priority in this case as the patient has lost a significant amount of weight and is neglecting self-care, such as bathing and eating properly. The weight loss indicates a serious issue that needs immediate attention to prevent further health complications. While self-care deficit, disturbed sleep pattern, and disturbed thought processes are also concerns for this patient, addressing the imbalanced nutrition takes precedence due to the potential impact on the patient's physical health. Neglecting proper nutrition can lead to serious complications, so it is crucial to address this issue first.
The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN?
- A. Transport a client who is receiving IV fluid to the radiology department
- B. Administer PRN oral analgesics to a client with a history of chronic pain
- C. Supervise a newly hired graduate nurse during an admission assessment
- D. Complete ongoing focused assessments of a client with wrist restraints
Correct Answer: C
Rationale: The correct answer is C because supervising a newly hired graduate nurse during an admission assessment is a task that falls within the registered nurse's scope of practice. Registered nurses are responsible for overseeing and delegating tasks, especially to new staff, to ensure proper assessment and care delivery. Choices A, B, and D involve tasks that can be appropriately assigned to practical nurses or unlicensed assistive personnel as they are within their scope of practice. Transporting a client, administering oral analgesics, and completing focused assessments do not require the advanced knowledge and skills of a registered nurse.
The client with diabetes mellitus type 1 has a fruity breath odor. What is the priority nursing action?
- A. Evaluate the client's intake and output
- B. Measure the client's capillary blood glucose
- C. Consult with the dietitian about the client's diet
- D. Apply a pulse oximeter to the client's finger
Correct Answer: B
Rationale: Fruity breath odor in a client with diabetes mellitus type 1 can indicate ketoacidosis, a serious complication. Measuring the client's capillary blood glucose is the priority nursing action in this scenario as it helps diagnose and manage the condition effectively. Evaluating intake and output may be important for overall assessment but not the priority when dealing with a potential emergency like ketoacidosis. Consulting with a dietitian about the client's diet is important for long-term management but not the immediate priority. Applying a pulse oximeter is not relevant to addressing the fruity breath odor and suspected ketoacidosis.