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A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?
- A. A client who is scheduled for a procedure in 1 hr.
- B. A client who received a pain medication 30 min ago for postoperative pain.
- C. A client who was just given a glass of orange juice for a low blood glucose level.
- D. A client who has 100 mL of fluid remaining in his IV bag.
Correct Answer: C
Rationale: The nurse should assess client C first because low blood glucose levels can lead to serious complications if not addressed promptly. Hypoglycemia can result in altered mental status, seizures, and even coma. Assessing and addressing this client's low blood glucose level is a priority to prevent further deterioration.
Clients A, B, and D do not have immediate life-threatening conditions that require urgent assessment compared to client C. Client A, scheduled for a procedure in 1 hr, can be assessed after client C. Client B, who received pain medication 30 min ago, would have some time before needing reassessment. Client D, with 100 mL of fluid remaining in the IV bag, can also wait as long as there is no indication of the client being dehydrated or in need of immediate intervention.
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A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence the nurse should follow to perform suctioning.
- A. Rinse the catheter to remove secretions.
- B. Insert the catheter during the client's inspiration.
- C. Turn on the suction and set the pressure.
- D. Don sterile gloves
- E. Apply sunction while rotating catheter
Correct Answer: D,C,B,E,A
Rationale: Correct Order: D, C, B, E, A
Rationale:
1. Don sterile gloves (D): Ensures infection control and prevents cross-contamination.
2. Turn on suction and set pressure (C): Prepares equipment and ensures proper functioning.
3. Insert catheter during client's inspiration (B): Reduces risk of inducing hypoxia.
4. Apply suction while rotating catheter (E): Maximizes removal of secretions.
5. Rinse catheter to remove secretions (A): Ensures cleanliness and prevents re-introduction of secretions.
Summary of Incorrect Choices:
- F and G are not applicable in this sequence.
- Inserting the catheter during inspiration (B) is correct, not during expiration.
- Rinsing the catheter (A) is done after suctioning, not before.
A nurse is caring for a client who has acute glomerulonephritis. Which of the following findings should the nurse expect?
- A. Oliguria
- B. Hypotension
- C. Weight loss
- D. Hematuria
Correct Answer: D
Rationale: The correct answer is D: Hematuria. In acute glomerulonephritis, there is inflammation of the glomeruli in the kidneys, leading to blood in the urine. This is due to damage to the glomerular capillaries allowing red blood cells to leak into the urine. Oliguria (A) is not a common finding as there is usually normal to increased urine output. Hypotension (B) is not typically seen as glomerulonephritis can lead to fluid overload and hypertension. Weight loss (C) is unlikely as fluid retention is common. Hematuria (D) is the hallmark finding due to the damage to glomeruli.
A nurse is providing discharge teaching to the partner of a client who has a tracheostomy. Which of the following information should the nurse include in the teaching?
- A. How to operate the portable suction machine
- B. How to secure the tracheostomy tube with ties at the back of the neck
- C. How to change the nondisposable tracheostomy tube daily
- D. How to change the tracheostomy dressing using clean technique
Correct Answer: A
Rationale: The correct answer is A: How to operate the portable suction machine. This information is crucial in maintaining a patent airway for the client with a tracheostomy. Suctioning helps to remove secretions and prevent blockages, ensuring proper oxygenation. It is essential for the partner to know how to operate the suction machine safely and effectively.
Choice B is incorrect as securing the tracheostomy tube with ties is important, but it is not the priority in this scenario. Choice C is incorrect as changing the nondisposable tracheostomy tube daily is not a standard practice and can introduce infection risk. Choice D is incorrect as changing the tracheostomy dressing should be done using sterile technique, not clean technique, to prevent infection.
A nurse is assisting with the care of a client who has a prescription for IV therapy. The client tells the nurse that he has numerous allergies. Which of the following allergies should the nurse bring to the attention of the charge nurse prior to the initiation of the therapy?
- A. Latex
- B. Seafood
- C. Bee stings
- D. Peanuts
Correct Answer: A
Rationale: Correct Answer: A (Latex)
Rationale: Latex allergies can lead to severe reactions, including anaphylaxis, if the client comes into contact with latex during IV therapy. It is crucial to inform the charge nurse to ensure alternative materials are used to prevent a life-threatening allergic reaction.
Summary of other choices:
B: Seafood - While seafood allergies are common, they are not directly related to IV therapy unless the IV solution contains seafood-derived components.
C: Bee stings - Bee sting allergies are important but are not directly relevant to IV therapy unless there is a risk of exposure during the procedure.
D: Peanuts - Peanut allergies are significant but do not pose a direct threat during IV therapy unless peanuts are present in the IV solution or equipment.
A nurse is reviewing a client's cardiac rhythm strips and notes a constant P-R interval of 0.35 seconds. Which of the following dysrhythmias is the client displaying?
- A. First-degree atrioventricular block
- B. Complete heart block
- C. Premature atrial complexes
- D. Atrial fibrillation
Correct Answer: A
Rationale: The correct answer is A: First-degree atrioventricular block. A constant P-R interval of 0.35 seconds indicates a delay in the conduction of electrical impulses from the atria to the ventricles. In first-degree AV block, the delay causes a prolonged P-R interval, which is consistent with the 0.35 seconds observed. This dysrhythmia is characterized by a consistent delay but all atrial impulses are conducted to the ventricles.
B: Complete heart block would show a lack of association between P waves and QRS complexes, with no relationship between atrial and ventricular activity.
C: Premature atrial complexes are early electrical impulses originating in the atria, resulting in abnormal P waves and irregular rhythm, not a constant P-R interval.
D: Atrial fibrillation is characterized by chaotic electrical activity in the atria, leading to an irregularly irregular ventricular response, not a constant P-R interval.