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What action should the nurse implement in caring for a client following an electroencephalogram (EEG)?
- A. Monitor the client's vital signs every 4 hours
- B. Assess the client's lower extremities for sensation
- C. Instruct the client to maintain bed rest
- D. Wash any paste from the client's hair and scalp
Correct Answer: D
Rationale: The correct action the nurse should implement after an EEG is to wash any paste from the client's hair and scalp. This is crucial to prevent irritation and infection at the EEG site. Monitoring vital signs every 4 hours is not specifically indicated after an EEG. Assessing the client's lower extremities for sensation is unrelated to caring for a client post-EEG. While rest may be recommended after the procedure, there is no standard requirement for a specific duration of bed rest.
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When caring for a client with a tracheostomy, what is the most important assessment to perform?
- A. Check the client's oxygen saturation
- B. Assess the tracheostomy site for signs of infection
- C. Monitor the client's respiratory rate
- D. Ensure the tracheostomy ties are secure
Correct Answer: A
Rationale: The most important assessment to perform when caring for a client with a tracheostomy is to check the client's oxygen saturation. This assessment is crucial as it ensures that the client is receiving adequate oxygen through the tracheostomy. Monitoring oxygen saturation provides immediate information on the client's respiratory status and the effectiveness of the airway management. Assessing the tracheostomy site for signs of infection is important but not as critical as ensuring adequate oxygenation. Monitoring the respiratory rate is also essential but does not directly assess the effectiveness of oxygenation. Ensuring tracheostomy ties are secure is important for maintaining the device but does not directly evaluate the client's oxygenation status.
A client with hypothyroidism is being treated with levothyroxine (Synthroid). What is the most important information for the nurse to provide to the client?
- A. Take the medication on an empty stomach
- B. Monitor for signs of hyperthyroidism
- C. Expect to see results within a week
- D. Avoid exposure to sunlight
Correct Answer: B
Rationale: The most important information for the nurse to provide to a client with hypothyroidism being treated with levothyroxine is to monitor for signs of hyperthyroidism. Too much levothyroxine can lead to symptoms of hyperthyroidism, indicating an overdose. Choice A is incorrect as levothyroxine is usually taken on an empty stomach to ensure optimal absorption. Choice C is inaccurate as it may take weeks to months to see the full effects of levothyroxine therapy due to the need for dosage adjustments. Choice D is unrelated to levothyroxine therapy and is not a crucial concern for this specific medication.
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is experiencing shortness of breath. What is the priority nursing intervention?
- A. Administer bronchodilator therapy as prescribed.
- B. Inhale the medication slowly while pressing down on the inhaler.
- C. Position the client in a high-Fowler's position.
- D. Increase the oxygen flow rate.
Correct Answer: C
Rationale: The priority nursing intervention for a client with COPD experiencing shortness of breath is to position the client in a high-Fowler's position. This position helps improve lung expansion and ease breathing by maximizing chest expansion and allowing for better airflow. While administering bronchodilator therapy is important, positioning the client for improved breathing takes priority. Inhaling the medication slowly and pressing down on the inhaler is a correct technique for inhaler use but not the priority intervention. Increasing the oxygen flow rate may be needed, but adjusting the client's position to a high-Fowler's position is the priority to address the shortness of breath in COPD.
The nurse observes a client with new-onset tachycardia. What should the nurse do first?
- A. Check for the client's temperature
- B. Administer prescribed beta-blockers
- C. Assess for any chest pain or discomfort
- D. Monitor the client's blood pressure
Correct Answer: C
Rationale: When a client presents with new-onset tachycardia, the first action the nurse should take is to assess for any associated symptoms like chest pain or discomfort. This is important to differentiate the potential causes of tachycardia and guide appropriate interventions. Checking the client's temperature (Choice A) may be relevant in certain situations but is not the priority when tachycardia is observed. Administering prescribed beta-blockers (Choice B) should only be done after a comprehensive assessment and healthcare provider's orders. Monitoring the client's blood pressure (Choice D) is important, but assessing for chest pain or discomfort takes precedence in this scenario to rule out cardiac causes of tachycardia.
The nurse is assessing a client who has just received a blood transfusion. The client reports chills and back pain. What is the nurse's priority action?
- A. Slow the rate of transfusion.
- B. Administer an antipyretic.
- C. Stop the transfusion immediately.
- D. Notify the healthcare provider.
Correct Answer: C
Rationale: The correct answer is C: Stop the transfusion immediately. Chills and back pain are indicative of a possible transfusion reaction, which is a critical situation. Stopping the transfusion is crucial to prevent further complications and ensure the client's safety. Slowing the rate of transfusion (Choice A) is not sufficient in this case as immediate action is required. Administering an antipyretic (Choice B) may help with fever but does not address the potential severe reaction. Notifying the healthcare provider (Choice D) can be done after stopping the transfusion, but the priority is to halt the infusion to prevent harm.