Nokea
Upon admission to the hospital, a client reports having "the worst headache I've ever had." The nurse should give the highest priority to which action?
- A. Administering pain medication
- B. Starting oxygen
- C. Performing neuro checks
- D. Inserting a Foley catheter
Correct Answer: C
Rationale: A severe headache may indicate a neurological emergency (e.g., subarachnoid hemorrhage). Neuro checks (C) assess for deterioration. Pain medication (A), oxygen (B), and Foley (D) are secondary.
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Which of the following instructions should be included in the nurse's teaching regarding oral contraceptives?
- A. Weight gain should be reported to the physician.
- B. An alternate method of birth control is needed when taking antibiotics.
- C. If the client misses one or more pills,two pills should be taken per day for one week.
- D. Changes in the menstrual flow should be reported to the physician.
Correct Answer: B
Rationale: Antibiotics can reduce the effectiveness of oral contraceptives by altering gut flora necessitating an alternate birth control method during antibiotic use. Weight gain and menstrual changes are common and doubling pills is not the correct protocol for missed doses.
The nurse is caring for a client with a history of a spinal cord injury who is experiencing autonomic dysreflexia. The nurse should:
- A. Place the client in a prone position
- B. Administer a vasodilator
- C. Insert a Foley catheter immediately
- D. Elevate the head of the bed
Correct Answer: C
Rationale: Autonomic dysreflexia is often triggered by bladder distension. Inserting a Foley catheter relieves the trigger. Vasodilators and positioning are secondary, and prone position is unsafe.
A client with a history of a kidney transplant is being discharged. The nurse should teach the client to:
- A. Monitor for signs of infection
- B. Eat a high-sodium diet
- C. Limit physical activity
- D. Take antibiotics daily
Correct Answer: A
Rationale: Immunosuppression post-kidney transplant increases infection risk, requiring vigilant monitoring. High-sodium diets, activity limits, and daily antibiotics are not standard.
A client has been admitted to the nursing unit with the diagnosis of severe anemia. She is slightly short of breath, has episodes of dizziness, and complains her heart sometimes feels like it will 'beat out of her chest.' The physician has ordered her to receive 2 U of packed red blood cells. The most important nursing action to be taken is:
- A. Starting an 18-gauge IV infusion
- B. Having the consent form on the chart
- C. Administering the correct blood product to the correct client
- D. Transfusing the blood in a 2-hour time frame
Correct Answer: C
Rationale: An 18-gauge IV is an appropriate size for administering blood; however, client safety demands that the right blood product must be administered. The consent form is legally necessary to be on the chart, but client safety is maintained by giving the correct blood component to the correct client. Administering the correct blood product to the correct client will maintain physiological safety and minimize transfusion reactions. The blood administration should take place over the ordered time frame designated by the physician.
A 10-year-old boy has been diagnosed with Legg-Calvé Perthes disease. Which of the client's responses would indicate compliance during initial therapy?
- A. Drinking large amounts of milk
- B. Not bearing weight on affected extremity
- C. Walking short distances 3 times/day
- D. Putting self on weight reduction diet
Correct Answer: B
Rationale: This condition causes aseptic necrosis of the head of the femur in the acetabulum. Drinking large quantities of milk at this time cannot hasten recovery. The aim of treatment is to keep the head of the femur in the acetabulum. Nonweight-bearing is essential. Activity causes microfractures of the epiphysis. In addition to nonweight-bearing, clients are often placed on bedrest, which helps to reduce inflammation. Later, active motion is encouraged. Weight is not generally an issue with this disease. Slipped femoral capital epiphysis, which is most frequently observed in obese pubescent children, usually requires a weight reduction diet.