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What actions should the nurse take regarding an older adult male who had an abdominal cholecystectomy and has become increasingly confused and disoriented over the past 24 hours, found wandering into another client's room and returned to his own room by the unlicensed assistive personnel (UAP)? (Select all that apply)
- A. Apply soft upper limb restraints and raise all four bed rails
- B. Report mental status change to the healthcare provider
- C. Assess the client's breath sounds and oxygen saturation
- D. Assign the UAP to re-assess the client's risk for falls
Correct Answer: B
Rationale: In this situation, the appropriate action for the nurse to take is to report the mental status change to the healthcare provider. Confusion and disorientation post-surgery can be indicative of various factors, such as electrolyte imbalances or respiratory issues, necessitating comprehensive assessment by the healthcare team. Applying restraints and raising bed rails may not address the underlying cause of the confusion, and assigning the UAP to reassess the client's risk for falls does not directly address the cognitive changes observed.
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Which assessment is most important for the nurse to perform before ambulating a client with a history of syncope?
- A. Pedal pulses
- B. Breath sounds
- C. Oxygen saturation
- D. Blood pressure
Correct Answer: D
Rationale: The correct answer is 'D: Blood pressure.' It is crucial to check the client's blood pressure before ambulating them, especially if they have a history of syncope. Monitoring blood pressure helps to prevent falls by ensuring that the client's blood pressure is stable enough to tolerate the activity. Choices A, B, and C are not as critical in this scenario. Checking pedal pulses, breath sounds, or oxygen saturation is important but not as crucial as assessing blood pressure when preparing to ambulate a client with a history of syncope.
A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely?
- A. Hypokalemia
- B. Ketonuria
- C. Peripheral edema
- D. Elevated blood pressure
Correct Answer: A
Rationale: The correct answer is A: Hypokalemia. In diabetes insipidus, there is excessive urination leading to fluid loss, which can result in electrolyte imbalances such as hypokalemia. Monitoring potassium levels is crucial to prevent complications like cardiac arrhythmias. Choices B, C, and D are incorrect. Ketonuria is typically seen in diabetic ketoacidosis, peripheral edema is more commonly associated with conditions like heart failure or kidney disease, and elevated blood pressure is not a direct complication of diabetes insipidus related to a pituitary gland tumor.
A 20-year-old male client is diagnosed with Ewing's sarcoma following an examination for a knee injury. Which instruction is most important for the nurse to provide the client?
- A. Take analgesics regularly to manage pain
- B. Notify the healthcare provider if the swelling worsens
- C. Avoid weight-bearing on the affected knee until the injury heals
- D. Seek treatment for the sarcoma immediately
Correct Answer: D
Rationale: The most crucial instruction for the nurse to provide the client is to seek treatment for the sarcoma immediately. Ewing's sarcoma is a type of cancer that necessitates prompt and aggressive treatment for the best possible outcome. While managing pain (Choice A) and monitoring swelling (Choice B) are important, addressing the underlying sarcoma is the priority. Instructing the client to avoid weight-bearing (Choice C) is not directly related to the treatment of Ewing's sarcoma and may not be the most critical instruction at this point.
Which medication should the nurse anticipate administering to a client who is diagnosed with myxedema coma?
- A. Intravenous administration of thyroid hormones
- B. Oral administration of hypnotic agents
- C. Intravenous bolus of hydrocortisone
- D. Subcutaneous administration of vitamin K
Correct Answer: A
Rationale: The correct answer is A: Intravenous administration of thyroid hormones. Myxedema coma is a severe form of hypothyroidism that necessitates immediate replacement of thyroid hormones. Administering thyroid hormones intravenously ensures rapid absorption and effectiveness in managing the condition. Choice B, oral administration of hypnotic agents, is incorrect as it does not address the primary issue of thyroid hormone deficiency in myxedema coma. Choice C, intravenous bolus of hydrocortisone, is not the appropriate treatment for myxedema coma as adrenal insufficiency is not the primary concern in this condition. Choice D, subcutaneous administration of vitamin K, is unrelated to the management of myxedema coma and does not address the underlying thyroid hormone deficiency that characterizes this condition.
Which intervention should the nurse include in a long-term plan of care for a client with Chronic Obstructive Pulmonary Disease (COPD)?
- A. Reduce risk factors for infection
- B. Administer high-flow oxygen during sleep
- C. Limit fluid intake to reduce secretions
- D. Use diaphragmatic breathing to achieve better exhalation
Correct Answer: D
Rationale: The correct answer is D. Diaphragmatic breathing is a beneficial intervention for clients with COPD as it helps improve breathing efficiency and manage symptoms by promoting better air exchange in the lungs. It aids in achieving better exhalation, reducing air trapping, and enhancing overall lung function. Choices A, B, and C are incorrect. While reducing risk factors for infection is important for overall health, it is not a specific long-term intervention for COPD. Administering high-flow oxygen during sleep may be necessary in some cases but is not typically a long-term strategy for managing COPD. Limiting fluid intake to reduce secretions is not recommended as hydration is essential for individuals with COPD to maintain optimal respiratory function and prevent complications like mucus plugs.