Nokea
Which intervention should the nurse implement to enhance the efficacy of the client's asthma medication therapy?
- A. Administer the albuterol inhaler before other inhaled medications.
- B. Provide oxygen via nasal cannula at 2 liters/minute.
- C. Encourage the client to drink three liters of fluids daily.
- D. Keep the client upright during nebulizer therapy.
Correct Answer: A
Rationale: The correct answer is A: Administer the albuterol inhaler before other inhaled medications. Administering albuterol first helps open airways, allowing better absorption of subsequent medications. Option B does not directly enhance medication efficacy. Option C promotes hydration but doesn't affect medication efficacy. Option D does not specifically enhance medication therapy.
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A client with a history of diabetes mellitus is admitted with a foot ulcer. The nurse should recognize that which intervention is most critical in promoting healing of the foot ulcer?
- A. Strict control of blood glucose levels.
- B. Regular dressing changes with sterile technique.
- C. Application of antibiotic ointment.
- D. Hydrotherapy treatment daily.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Strict control of blood glucose levels is critical in promoting healing of foot ulcers in diabetic patients.
2. High blood glucose levels can impair wound healing by affecting circulation and immune response.
3. Maintaining normal glucose levels helps optimize tissue repair and prevent further complications.
4. Regular dressing changes (B) are important but not as critical as controlling blood glucose levels.
5. Application of antibiotic ointment (C) may be necessary for infected ulcers, but not the most critical intervention.
6. Hydrotherapy treatment (D) can help with wound cleansing, but it is not as essential as controlling blood glucose levels.
The nurse is caring for four clients: Client A, who has emphysema and an oxygen saturation of 94%; Client B, with a postoperative hemoglobin of 8.7 g/dL; Client C, newly admitted with a potassium level of 3.8 mEq/L; and Client D, scheduled for an appendectomy with a white blood cell count of 15,000/mm3. What intervention should the nurse implement?
- A. Increase Client A's oxygen to 4 liters per minute via nasal cannula.
- B. Determine if Client B has two units of packed cells available in the blood bank.
- C. Ask the dietitian to add a banana to Client C's breakfast tray.
- D. Inform Client D that surgery is likely to be delayed until the infection is treated.
Correct Answer: D
Rationale: The correct answer is D because a white blood cell count of 15,000/mm3 indicates an infection, which can be a contraindication for surgery. The nurse should inform Client D that surgery is likely to be delayed until the infection is treated to prevent complications.
Choice A is incorrect as increasing oxygen for Client A may not be necessary based on the oxygen saturation level of 94%, which is within the normal range.
Choice B is incorrect because determining if packed cells are available in the blood bank for Client B with a hemoglobin of 8.7 g/dL does not address the immediate concern of the possible surgical delay due to infection.
Choice C is incorrect as adding a banana to Client C's breakfast tray for a potassium level of 3.8 mEq/L is not a priority compared to addressing the potential surgical delay for Client D.
A primipara at 38-weeks gestation is admitted to labor and delivery for a biophysical profile (BPP). The nurse should prepare the client for what procedures?
- A. Chorionic villus sampling under ultrasound.
- B. Amniocentesis and fetal monitoring.
- C. Ultrasonography and nonstress test.
- D. Oxytocin challenge test and fetal heart rate monitoring.
Correct Answer: C
Rationale: The correct answer is C: Ultrasonography and nonstress test. At 38 weeks gestation, a biophysical profile (BPP) is typically done to assess fetal well-being. Ultrasonography is used to evaluate fetal movements, tone, breathing movements, and amniotic fluid volume. The nonstress test assesses fetal heart rate in response to fetal movement, indicating fetal well-being. Chorionic villus sampling (A) and amniocentesis (B) are invasive procedures not typically done as part of a routine BPP. Oxytocin challenge test (D) is not indicated in this scenario as it is used to assess placental function in high-risk pregnancies.
A client who has Type 1 diabetes and is at 10-weeks gestation comes to the prenatal clinic complaining of a headache, nausea, sweating, feeling shaky, and being tired all the time. What action should the nurse take first?
- A. Check the blood glucose level.
- B. Draw blood for a Hemoglobin A1C.
- C. Assess urine for ketone levels.
- D. Provide the client with a protein snack.
Correct Answer: A
Rationale: The correct answer is A: Check the blood glucose level. This is the first action the nurse should take because the client is presenting with symptoms of hypoglycemia, which can be life-threatening for a pregnant woman with Type 1 diabetes. By checking the blood glucose level, the nurse can determine if the client's symptoms are due to low blood sugar levels and take appropriate action. Drawing blood for a Hemoglobin A1C (choice B) is not the first priority in this acute situation. Assessing urine for ketone levels (choice C) is important in managing diabetes but is not the priority when the client is showing signs of hypoglycemia. Providing the client with a protein snack (choice D) may help raise blood sugar levels, but checking the blood glucose level is essential to determine the appropriate intervention.
The client has acute kidney injury (AKI). Which assessment finding requires immediate intervention?
- A. Urine output of 50 ml in the last hour.
- B. Serum potassium of 6.2 mEq/L.
- C. Blood pressure of 150/90 mm Hg.
- D. Serum creatinine of 2.5 mg/dL.
Correct Answer: B
Rationale: The correct answer is B: Serum potassium of 6.2 mEq/L. Hyperkalemia is a life-threatening condition in AKI. High potassium levels can lead to cardiac arrhythmias and must be addressed immediately. Choice A is concerning but not as critical as hyperkalemia. Choice C, elevated blood pressure, needs monitoring but does not require immediate intervention. Choice D, elevated serum creatinine, indicates kidney dysfunction but does not pose an immediate threat compared to hyperkalemia.