Nokea
The nurse provides discharge teaching to a client who was recently diagnosed with diabetes mellitus (DM). After receiving the instructions, the client expresses understanding about when, how, and why to take his prescribed medications at home. Which intervention is most important for the nurse to implement?
- A. Review the purpose of medications prescribed for the client to take home with him
- B. Provide the client with a printed list of medications and a schedule for administration
- C. Send a list of medications taken while hospitalized to the client's healthcare provider
- D. Offer to consult with the pharmacist about resources for reduced-price medications
Correct Answer: B
Rationale: Providing the client with a printed list of medications and a schedule for administration is crucial to ensure adherence and understanding of the medication regimen at home. This intervention helps the client follow the prescribed treatment plan accurately. Choice A is not as essential since the client already understands when, how, and why to take the medications. Choice C is not a priority at this point as the client needs information for home medication management. Choice D, while helpful, is not the most important intervention compared to providing a clear list and schedule for medication administration.
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A male client reports the onset of numbness and tingling in his fingers and around his mouth. Which lab value is important for the nurse to review before contacting the health care provider?
- A. capillary glucose
- B. urine specific gravity
- C. Serum calcium
- D. white blood cell count
Correct Answer: C
Rationale: The correct answer is C: Serum calcium. Numbness and tingling can be indicative of hypocalcemia, which can affect the nervous system. Reviewing serum calcium levels is crucial to address this potential issue. Options A, B, and D are not directly related to the symptoms described by the client and are not typically associated with numbness and tingling around the mouth and fingers. Capillary glucose levels are more relevant in assessing for diabetes or monitoring glucose control. Urine specific gravity is useful in evaluating hydration status. White blood cell count is typically checked to assess infection or immune response, which are not indicated by the client's symptoms of numbness and tingling.
The nurse is admitting a client from the post-anesthesia unit to the postoperative surgical care unit. Which intervention should the nurse implement first?
- A. Advance to clear liquids as tolerated
- B. Straight catheterization if unable to void
- C. Administer Cefazolin 1 gram IVPQ q6 hours
- D. Obtain a complete blood cell count (CBC) in the morning
Correct Answer: B
Rationale: The correct answer is to perform straight catheterization if the client is unable to void. This action is essential to prevent urinary retention and its potential complications following anesthesia. Option A, advancing to clear liquids, is not the priority upon admission as the focus should be on urinary function first. Option C involves administering an antibiotic, which is important but not the immediate priority. Option D, obtaining a CBC, can be done later and is not as crucial as ensuring proper urinary function postoperatively.
The nurse assesses a 5-year-old child who has been experiencing frequent headaches and vomiting. The nurse notices that the child is lethargic and has a positive Brudzinski sign. Which action should the nurse implement first?
- A. Perform a complete neurological examination
- B. Measure the child's head circumference
- C. Check the child's blood glucose level
- D. Notify the healthcare provider immediately
Correct Answer: D
Rationale: The correct action for the nurse to implement first is to notify the healthcare provider immediately. The presence of lethargy and a positive Brudzinski sign in a child experiencing frequent headaches and vomiting may indicate a serious condition like meningitis. Prompt notification of the healthcare provider is crucial for timely evaluation and initiation of appropriate treatment.
Choice A is incorrect because while a neurological examination may be necessary, it is not the priority when a potentially serious condition like meningitis is suspected.
Choice B is incorrect as measuring the child's head circumference is not the most immediate action to take in this situation.
Choice C is also incorrect as checking the child's blood glucose level, although important in some cases, is not the priority when a child presents with symptoms suggestive of meningitis.
The nurse is caring for a newborn who arrives in the nursery following a precipitous birth on the way to the hospital. A drug screen of the mother reveals the presence of cocaine metabolites. The infant has a heart rate of 175 beats/minute, cries continuously, is irritable, and is hyperreactive to stimuli. Which intervention is most important for the nurse to include in this infant's plan of care?
- A. Initiate infant sepsis protocol
- B. Implement seizure precautions
- C. Refer to protective child services
- D. Formula feed every 3 hours
Correct Answer: B
Rationale: The infant's symptoms, such as a high heart rate, continuous crying, irritability, and hyperreactivity, suggest possible withdrawal effects due to maternal cocaine use. These symptoms can lead to seizures. Therefore, the priority intervention is to implement seizure precautions to ensure the infant's safety. Initiating the infant sepsis protocol is not indicated based on the symptoms presented. Referring to protective child services is important but not the immediate priority. Formula feeding every 3 hours is a routine care measure but does not address the urgent need to prevent potential seizures.
An older male client arrives at the clinic complaining that his bladder always feels full. He complains of a weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating his urine stream. What action should the nurse implement?
- A. Palpate the client's suprapubic area for distention
- B. Advise the client to maintain a voiding diary for one week
- C. Instruct the client in effective techniques for cleansing the glans penis
- D. Obtain a urine specimen for culture and sensitivity
Correct Answer: B
Rationale: Advising the client to maintain a voiding diary is the appropriate action in this case. A voiding diary helps track symptoms and patterns essential for diagnosing conditions like benign prostatic hyperplasia or other urinary issues. Palpating the client's suprapubic area for distention (Choice A) may provide information about bladder fullness but does not address the need for tracking symptoms. Instructing the client in techniques for cleansing the glans penis (Choice C) is not relevant to the client's urinary complaints. Obtaining a urine specimen for culture and sensitivity (Choice D) may be necessary but does not directly address the client's symptoms of weak urine flow and difficulty initiating the urine stream.