Nokea
A client is admitted to the unit with pregnancy-induced hypertension (PIH).
Which of the following actions is the priority nursing action?
- A. Start an IV.
- B. Obtain the vital signs.
- C. Administer magnesium sulfate.
- D. Notify the lab to draw blood.
Correct Answer: B
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes. (1) implementation, not a priority action (2) correct-assessment, important to do a baseline assessment in order to successfully evaluate the treatment (3) implementation, not a priority action (4) implementation, not a priority action
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The nurse is caring for a client with a history of Crohn’s disease.
- A. Which dietary instruction is most appropriate for a client with Crohn’s disease?
- B. High-fiber diet during remission.
- C. Low-residue diet during exacerbations.
- D. High-fat diet to increase calories.
- E. Avoid all dairy products.
Correct Answer: B
Rationale: A low-residue diet during Crohn’s disease exacerbations reduces bowel irritation. High-fiber is used in remission, high-fat diets worsen symptoms, and dairy is avoided only if intolerant.
The nurse is caring for a client with a history of seizures. The client begins to experience a tonic-clonic seizure. Which of the following actions should the nurse take FIRST?
- A. Restrain the client to prevent injury.
- B. Place a tongue depressor in the client's mouth.
- C. Turn the client to the side.
- D. Administer lorazepam (Ativan) IV.
Correct Answer: C
Rationale: turning the client to the side helps maintain a patent airway and prevents aspiration during a seizure
The nurse is caring for a client with a nasogastric (NG) tube. Which of the following actions should the nurse take to ensure proper functioning of the NG tube?
- A. Irrigate the tube with 50 mL of sterile water every 4 hours.
- B. Check for residual volume every 8 hours.
- C. Secure the tube to the client's gown only.
- D. Keep the head of the bed flat at all times.
Correct Answer: B
Rationale: checking residual volume ensures the tube is functioning and prevents overfeeding or aspiration
The nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following laboratory values should the nurse monitor closely?
- A. Serum potassium.
- B. Hemoglobin A1c.
- C. Platelet count.
- D. Serum creatinine.
Correct Answer: A
Rationale: TPN can cause electrolyte imbalances, particularly hyperkalemia or hypokalemia
A client has received thrombolytic therapy, and the physician has ordered meperidine (Demerol) IM for pain. Before administering the injection, the nurse should
- A. confirm that all lab work has been completed.
- B. verify the order with the physician.
- C. check the client's PTT.
- D. determine that all of the thrombolytic agent has infused.
Correct Answer: B
Rationale: implementation, complications of thrombolytic therapy include bleeding, which can occur with intramuscular injections; nurse should confer with the physician about the appropriateness of the order