Nokea
Which nursing diagnosis has the highest priority when planning care for a client in cardiogenic shock?
- A. Risk for imbalanced body temperature
- B. Excess fluid volume
- C. Fatigue
- D. Ineffective Tissue Perfusion
Correct Answer: D
Rationale: In cardiogenic shock, the priority nursing diagnosis is Ineffective Tissue Perfusion. This diagnosis indicates that the client is not receiving adequate oxygenated blood to tissues, putting vital organs at risk. Addressing ineffective tissue perfusion is crucial to prevent organ damage and ensure the client's survival. The other options, such as 'Risk for imbalanced body temperature,' 'Excess fluid volume,' and 'Fatigue,' are important but secondary to the immediate threat of inadequate tissue perfusion in cardiogenic shock.
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A 9-year-old boy with tetralogy of Fallot is being discharged following a cardiac catheterization. Which discharge instruction should the nurse provide the parents?
- A. Do not allow the child to return to school for at least one month
- B. Notify the healthcare provider if there is any drainage at the catheterization site
- C. Monitor the child's temperature and report any elevation
- D. Observe for any changes in the child's color or energy level
Correct Answer: B
Rationale: The correct answer is to notify the healthcare provider if there is any drainage at the catheterization site. Drainage at the site can be a sign of infection, which needs prompt evaluation and treatment. Choices A, C, and D are not as crucial as identifying and reporting any drainage, which is more directly related to potential complications post-cardiac catheterization.
The nurse is preparing to administer the 0800 dose of 20 units of Humulin R to an 8-year-old girl diagnosed with Type 1 diabetes. The mother comments that her daughter is a very picky eater and many times does not eat meals. Which intervention should the nurse implement first?
- A. Administer the 20 Units of Humulin R subcutaneously as prescribed
- B. Ask the girl if she will be eating her breakfast this morning
- C. Discuss changing the insulin prescription to Lispro with the healthcare provider
- D. Explain to the mother the importance of eating the scheduled meals
Correct Answer: B
Rationale: The correct answer is to ask the girl if she will be eating her breakfast this morning. This is important to determine if the child will be consuming food, which is crucial information before administering insulin. If the child does not plan to eat, administering the full dose of insulin may lead to hypoglycemia. Choice A is incorrect as administering the insulin without knowing if the child will eat can be dangerous. Choice C is not the first intervention because the immediate concern is the child's meal intake. Choice D, while important, is not the first step in this situation.
A client with diabetes mellitus reports feeling shaky and has a blood glucose level of 60 mg/dl. What action should the nurse take?
- A. Administer 15 grams of carbohydrate
- B. Administer a glucagon injection
- C. Provide a snack with protein
- D. Encourage the client to rest
Correct Answer: A
Rationale: In the scenario described, the client is experiencing hypoglycemia with a blood glucose level of 60 mg/dl. The appropriate action for the nurse to take is to administer 15 grams of carbohydrate. Carbohydrate intake helps to rapidly raise blood sugar levels in cases of hypoglycemia. Administering a glucagon injection (Choice B) is not the initial treatment for mild hypoglycemia; it is typically used for severe hypoglycemia when the client is unable to consume oral carbohydrates. Providing a snack with protein (Choice C) is not the first-line intervention for hypoglycemia; immediate carbohydrate intake is necessary to raise blood sugar levels quickly. Encouraging the client to rest (Choice D) may be appropriate after administering the carbohydrate, but the priority is to address the low blood glucose levels by administering carbohydrates first.
One hour after delivery, the nurse is unable to palpate the uterine fundus of a client and notes a large amount of lochia on the perineal pad. Which intervention should the nurse implement first?
- A. Empty the bladder using an indwelling urinary catheter
- B. Increase the rate of the IV containing oxytocin (Pitocin)
- C. Assess for shock by determining the blood pressure
- D. Perform gentle massage at the level of the umbilicus
Correct Answer: D
Rationale: Gentle massage at the level of the umbilicus is the initial intervention to help contract the uterus and reduce bleeding, which is crucial in managing postpartum hemorrhage. Emptying the bladder can help with fundal displacement, but massage should be done first to stimulate uterine contractions. Increasing the IV oxytocin rate is a possible intervention but not the initial priority. Assessing for shock is important, but addressing the uterine atony through massage takes precedence to prevent further hemorrhage.
A healthcare provider is assessing a client who is receiving treatment for dehydration. Which assessment finding indicates that the client is responding to the treatment?
- A. Dry mucous membranes
- B. Increased urine output
- C. Decreased skin turgor
- D. Elevated heart rate
Correct Answer: B
Rationale: Increased urine output is a positive sign indicating that the client is responding to the treatment for dehydration. It suggests that the client's kidneys are functioning better, helping to eliminate excess fluid and waste products from the body. Dry mucous membranes (Choice A) are a sign of dehydration, not improvement. Decreased skin turgor (Choice C) and elevated heart rate (Choice D) are also symptoms of dehydration and do not indicate a positive response to treatment.