Nokea
What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke?
- A. Cholesterol level.
- B. Pupil size and pupillary response.
- C. Bowel sounds.
- D. Echocardiogram. SUPPRESSED
Correct Answer: B
Rationale: Pupil size and pupillary response are priority assessments to detect neurological deterioration, such as increased ICP or stroke extension. Cholesterol, bowel sounds, and echocardiograms are not immediate priorities.
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A nurse is treating a client who came to the emergency department after getting bit by a snake on their arm. After confirming the resuscitation equipment is at the bedside, which of the following actions by the nurse would be a priority?
- A. Contact Poison Control for guidance on an antivenom.
- B. Ensure the client's peripheral intravenous (IV) lines are patent.
- C. Apply a tourniquet above the snake bitten area on the arm.
- D. Assess for rash, fever, chills, nausea, vomiting, and joint pain.
Correct Answer: B
Rationale: Ensuring patent IV lines is the priority to enable rapid antivenom or fluid administration, critical for snakebite management. Contacting Poison Control (A) is secondary, tourniquets (C) are harmful, and symptom assessment (D) is important but not the immediate priority.
The client's serum potassium level is elevated in acute renal failure, and the nurse administers sodium polystyrene sulfonate (Kayexalate). This drug acts to:
- A. Increase potassium excretion from the colon.
- B. Release hydrogen ions for sodium ions.
- C. Increase calcium absorption in the colon.
- D. Exchange sodium for potassium ions in the colon.
Correct Answer: D
Rationale: Kayexalate exchanges sodium for potassium in the colon, reducing serum potassium levels in acute renal failure.
The nurse should teach the client with diverticulitis to integrate which of the following into a daily routine at home?
- A. Using enemas to relieve constipation.
- B. Decreasing fluid intake to increase the formed consistency of the stool.
- C. Eating a high-fiber diet when symptomatic with diverticulitis.
- D. Refraining from straining and lifting activities.
Correct Answer: D
Rationale: Refraining from straining and lifting activities prevents increased intra-abdominal pressure, reducing the risk of diverticulitis complications. Enemas, decreased fluid, or high-fiber diets during acute symptoms can worsen the condition. CN: Physiological adaptation; CL: Synthesize
When performing postural drainage, which of the following factors promotes the movement of secretions from the lower to the upper respiratory tract?
- A. Friction between the cilia.
- B. E. Force of gravity.
- C. Sweeping motion of cilia.
- D. Involuntary muscle contractions.
Correct Answer: B
Rationale: The force of gravity in postural drainage positions the body to allow secretions to drain from lower to upper airways. Cilia and muscle contractions aid clearance but are not the primary mechanism.
The nurse is teaching a caregiver how to administer an injection of a prefilled syringe of enoxaparin. Which statement, if made by the caregiver, would require further teaching?
- A. "I will give this injection in the abdomen."
- B. "I should expel the air bubble before administering."
- C. "Green leafy vegetables are allowed while taking this medication."
- D. "This medication may increase the risk for bleeding."
Correct Answer: B
Rationale: The air bubble in a prefilled enoxaparin syringe should not be expelled, as it ensures the full dose is administered.