Nokea
The nurse is speaking to a client who takes desmopressin nasal spray for diabetes insipidus. Which statement by the client is most important for the nurse to report to the health care provider?
- A. I am tired of restricting fluids but know that I need to.
- B. I feel like I am beginning to get sick with a bad cold.
- C. I have been getting a lot of nasal pain with this spray.
- D. I have recently started to experience frequent headaches.
Correct Answer: D
Rationale: Frequent headaches (D) may indicate overmedication or hyponatremia, requiring urgent reporting. Fluid restriction (A), colds (B), and nasal pain (C) are less critical.
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An 87-year-old client has been admitted to the hospital with signs and symptoms of a urinary tract infection along with agitation, confusion, and disorientation to time and place. What is the most important nursing action?
- A. Encouraging frequent fluid intake
- B. Keeping the bed elevated and side rails raised
- C. Providing one-on-one supervision
- D. Turning the lights off in the client's room
Correct Answer: C
Rationale: One-on-one supervision (C) ensures safety for a confused, agitated client at risk for falls or harm. Fluids (A), side rails (B), and dim lights (D) are secondary or inappropriate.
A client with a history of degenerative arthritis is being discharged home following exacerbation of chronic obstructive pulmonary disease. After reviewing the discharge medications, the nurse should reinforce which of the following topics with the client? Select all that apply.
- A. Dryness of the mouth and throat may occur
- B. Ringing in the ears is an expected, transient side effect
- C. The albuterol canister should not be shaken before use
- D. The health care provider should be notified if stools are black and tarry
- E. Tiotropium capsules should not be swallowed
Correct Answer: A,D,E
Rationale: Dry mouth (A) is a side effect of COPD medications, black stools (D) may indicate GI bleeding, and tiotropium capsules are inhaled, not swallowed (E). Ringing in ears (B) is not expected, and albuterol should be shaken (C).
An adult is scheduled for a paracentesis. What should the nurse plan to do immediately before the procedure is started?
- A. Give the client a full glass of water
- B. Have the client empty his/her bladder
- C. Ask the client to empty his/her bowels
- D. Administer diazepam (Valium) as ordered
Correct Answer: B
Rationale: Emptying the bladder before paracentesis prevents accidental puncture of the bladder during needle insertion into the abdominal cavity. Water intake, bowel emptying, or sedation are not immediate pre-procedure priorities.
An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be taken by the nurse is to:
- A. check the carotid pulse
- B. deliver 5 abdominal thrusts
- C. give 2 rescue breaths
- D. ensure an open airway
Correct Answer: D
Rationale: According to the ABCs of CPR, the first step in rescuing an unresponsive victim after checking responsiveness and calling for help is to open the victim's airway.
The nurse is caring for a 12 year-old with an acute illness. Which of the following indicates the nurse understands common sibling reactions to hospitalization?
- A. Younger siblings adapt very well
- B. Visitation is helpful for both
- C. The siblings may enjoy privacy
- D. Those cared for at home cope better
Correct Answer: B
Rationale: Visitation is helpful for both. Contact with the ill child helps siblings understand hospitalization and maintain relationships.