Nokea
When entering the room of an adult male, the nurse finds that the client is very anxious. Before providing care, what action should the nurse take first?
- A. Divert the client's attention
- B. Call for additional help from staff
- C. Document the planned action
- D. Re-assess the client's situation
Correct Answer: D
Rationale: Before providing care to an anxious client, it is crucial for the nurse to first re-assess the client's situation. By re-assessing, the nurse can understand the underlying cause of the client's anxiety, which will help in tailoring appropriate care interventions. Re-assessment ensures that care provided is individualized and addresses the client's specific needs, promoting effective and client-centered care delivery. Diverting the client's attention (Choice A) may not address the root cause of the anxiety. Calling for additional help (Choice B) may be necessary in some situations but should not be the first action. Documenting the planned action (Choice C) should come after re-assessing the client's situation to ensure accurate documentation based on the current assessment.
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The healthcare professional is monitoring a client receiving IV potassium chloride. Which assessment finding should prompt the healthcare professional to immediately stop the infusion?
- A. The client reports pain at the IV site
- B. The client's heart rate is irregular
- C. The client has swelling at the IV site
- D. The client's blood pressure is elevated
Correct Answer: B
Rationale: An irregular heart rate is a critical sign of hyperkalemia, a serious condition that can lead to life-threatening cardiac arrhythmias. Stopping the infusion promptly is crucial to prevent further complications. The healthcare professional should inform the healthcare provider immediately for further evaluation and management. Choice A is incorrect because pain at the IV site is common and may not necessitate stopping the infusion. Choice C is incorrect as swelling at the IV site may indicate a local reaction but is not a reason to stop the infusion. Choice D is incorrect as an elevated blood pressure alone is not a direct indication to stop the infusion of IV potassium chloride.
The healthcare provider plans to administer diazepam, 4 mg IV push, to a client with severe anxiety. How many milliliters should the healthcare provider administer? (Round to the nearest tenth.)
- A. 0.2 mL
- B. 0.8 mL
- C. 1.25 mL
- D. 2.0 mL
Correct Answer: B
Rationale: To calculate the volume to administer, use the formula (1 mL 4 mg) / 5 mg = 0.8 mL. The healthcare provider should administer 0.8 mL of diazepam for a dosage of 4 mg IV push. Choice A is incorrect because it results from an incorrect calculation. Choices C and D are incorrect as they do not align with the correct calculation based on the provided dosage.
When caring for an immobile client, what nursing diagnosis has the highest priority?
- A. Risk for fluid volume deficit.
- B. Impaired gas exchange.
- C. Risk for impaired skin integrity.
- D. Altered tissue perfusion.
Correct Answer: B
Rationale: When caring for an immobile client, the nursing diagnosis with the highest priority is impaired gas exchange. This is because impaired gas exchange implies difficulty with breathing, which is essential for sustaining life. Adequate oxygenation is crucial for all bodily functions, and any impairment in gas exchange can lead to serious complications, making it the priority nursing diagnosis to address in an immobile client. Choices A, C, and D are important considerations as well when caring for an immobile client, but they are secondary to impaired gas exchange. Risk for fluid volume deficit may occur due to immobility, but ensuring proper gas exchange takes precedence as it directly impacts the client's immediate survival. Risk for impaired skin integrity is a concern in immobile clients but does not pose an immediate threat to life like impaired gas exchange. Altered tissue perfusion is also critical but is usually a consequence of impaired gas exchange, reinforcing the priority of addressing gas exchange first.
The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction?
- A. Perform range-of-motion exercises to prevent contractures.
- B. Decrease the client's fluid intake to prevent diarrhea.
- C. Massage the client's legs to reduce the occurrence of embolisms.
- D. Turn the client from side to back every shift.
Correct Answer: A
Rationale: Performing range-of-motion exercises is essential in preventing contractures, which are common complications of immobility. These exercises help maintain joint flexibility and muscle strength, reducing the risk of contractures that can lead to functional limitations or pain for the client. Choices B, C, and D are incorrect. Decreasing fluid intake does not prevent immobility complications, but it can lead to dehydration. Massaging the client's legs does not directly address the prevention of immobility complications like contractures. Turning the client from side to back every shift is important for preventing pressure ulcers but does not directly address complications of immobility like contractures.
The nurse is providing discharge teaching to a client with a new diagnosis of osteoporosis. Which instruction should the nurse include?
- A. Increase dietary intake of calcium-rich foods.
- B. Avoid activities that increase the risk of falls.
- C. Avoid prolonged exposure to sunlight.
- D. Increase intake of vitamin D supplements.
Correct Answer: B
Rationale: Avoiding activities that increase the risk of falls (B) is the most crucial instruction for a client with osteoporosis to prevent fractures. Osteoporosis weakens bones, making them more susceptible to fractures from falls. While increasing calcium intake (A) is important for bone health, avoiding falls takes precedence to prevent immediate harm. Avoiding prolonged exposure to sunlight (C) is not directly related to osteoporosis management. Increasing vitamin D supplements (D) is beneficial for bone health, but fall prevention is more critical in this scenario.