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What is the most important assessment for a nurse to conduct on a child diagnosed with intussusception?
- A. Monitor for signs of infection.
- B. Measure abdominal girth and monitor for pain.
- C. Check for bowel movement and changes in stool.
- D. Assess hydration status and monitor urine output.
Correct Answer: C
Rationale: The correct answer is C: 'Check for bowel movement and changes in stool.' Intussusception can cause obstruction in the bowel, leading to symptoms like abdominal pain, vomiting, and 'currant jelly' stools. Monitoring for changes in bowel movement, especially the passage of 'currant jelly' stools, is crucial for early detection of worsening conditions. Choices A, B, and D are important assessments in pediatric care but are not as specific or crucial as checking for changes in bowel movement in a child diagnosed with intussusception.
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A client with cirrhosis develops ascites. What is the nurse's priority intervention?
- A. Administer diuretics as prescribed.
- B. Restrict fluid intake to manage fluid overload.
- C. Position the client in Fowler's position and assess for respiratory distress.
- D. Measure the client's abdominal girth daily.
Correct Answer: B
Rationale: The correct answer is B: Restrict fluid intake to manage fluid overload. In a client with cirrhosis developing ascites, the priority intervention is to restrict fluid intake. This helps manage fluid overload, prevent further complications, such as respiratory distress or kidney impairment, and reduce the accumulation of ascitic fluid. Administering diuretics may be a part of the treatment plan, but the primary focus should be on fluid restriction. Positioning the client in Fowler's position and measuring the abdominal girth are important interventions but not the priority when managing ascites in cirrhosis.
A nurse is working with a new graduate nurse on the delegation of tasks to the unlicensed assistive personnel (UAP). Which task would the new nurse need more teaching about delegating?
- A. Taking a client's blood pressure
- B. Providing oral hygiene for a client
- C. Assessing a client's pain level
- D. Assisting a client with ambulation
Correct Answer: C
Rationale: The correct answer is C: Assessing a client's pain level. This task involves clinical judgment and interpretation, which are within the scope of a licensed nurse's practice. Delegating pain assessment to unlicensed personnel could lead to errors in pain management and inappropriate interventions. Choices A, B, and D involve tasks that can be safely delegated to unlicensed assistive personnel as they do not involve interpretation or nursing judgment. Taking a client's blood pressure, providing oral hygiene, and assisting with ambulation are all routine tasks that can be appropriately assigned to UAP under the supervision of a licensed nurse.
A client with type 1 diabetes reports blurry vision. What is the most important assessment the nurse should perform?
- A. Assess the client's most recent blood glucose levels.
- B. Check the client's hemoglobin A1C level.
- C. Check the client's blood pressure for signs of hypertension.
- D. Examine the client's feet for signs of neuropathy.
Correct Answer: A
Rationale: Blurry vision in clients with type 1 diabetes may indicate hyperglycemia, which requires prompt assessment of recent blood glucose levels to determine the cause and appropriate intervention. Checking the client's hemoglobin A1C level (Choice B) is useful for assessing long-term glucose control, not for immediate management of blurry vision. Monitoring blood pressure (Choice C) is important in diabetes care but is not the most crucial assessment when blurry vision is reported. Examining the client's feet for signs of neuropathy (Choice D) is important in diabetic foot care but is not the priority when dealing with blurry vision.
A client with hypothyroidism is prescribed levothyroxine. What is the most important teaching point for the nurse to provide?
- A. Take the medication with food to avoid stomach upset.
- B. Take the medication at the same time every day to maintain consistent thyroid levels.
- C. Expect increased sensitivity to cold as a side effect of the medication.
- D. Increase the dosage of levothyroxine if symptoms worsen.
Correct Answer: B
Rationale: The correct answer is B. Levothyroxine should be taken at the same time every day to maintain stable thyroid hormone levels and ensure effective management of hypothyroidism. Consistent dosing is critical for preventing fluctuations in hormone levels. Choice A is incorrect because levothyroxine is usually recommended to be taken on an empty stomach for optimal absorption. Choice C is incorrect because increased sensitivity to cold is not a common side effect of levothyroxine. Choice D is incorrect because adjusting the dosage without healthcare provider guidance can be dangerous and should not be done independently.
A client with diabetes mellitus is scheduled for surgery. What is the nurse's priority action when preparing this client for surgery?
- A. Ensure the client is NPO before surgery
- B. Monitor the client's blood glucose levels
- C. Administer the client's insulin as scheduled
- D. Teach the client about postoperative care
Correct Answer: B
Rationale: The correct answer is B: Monitor the client's blood glucose levels. Clients with diabetes are at risk for perioperative complications related to blood glucose fluctuations. Monitoring blood glucose levels is crucial to maintaining proper management before, during, and after surgery. Option A is not the priority action as ensuring NPO status is a standard preoperative procedure for all clients. Option C could be important but is secondary to monitoring blood glucose levels. Option D is important but not the priority during the preoperative phase.