Nokea
Which of the following actions should the nurse take? (Select all that apply)
- A. Anticipate client to be prepped for cardiac catheterization
- B. Assist with a continuous heparin infusion
- C. Encourage the client to ambulate
- D. Anticipate an increase in dosage of metoprolol
- E. Obtain a prescription for client to be NPO
- F. Request a prescription for an antibiotic
Correct Answer: A, B, D,E
Rationale: The correct actions for the nurse to take are A, B, D, and E. A - anticipating client prep for cardiac catheterization is important for timely intervention. B - assisting with a continuous heparin infusion helps prevent blood clot formation during the procedure. D - anticipating an increase in metoprolol dosage is necessary to manage cardiac workload during the procedure. E - obtaining a prescription for NPO status is crucial to prevent complications during the procedure. Choices C (encouraging ambulation) and F (requesting an antibiotic prescription) are not directly related to preparing for cardiac catheterization and may not be necessary in this context.
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A nurse is caring for a client who has tuberculosis. Which of the following precautions should the nurse implement for this client?
- A. Standard precautions
- B. Airborne precautions
- C. Contact precautions
- D. Droplet precautions
Correct Answer: B
Rationale: The correct answer is B: Airborne precautions. Tuberculosis is transmitted through the air via droplet nuclei. Implementing airborne precautions includes wearing an N95 respirator, placing the client in a negative pressure room, and ensuring proper ventilation. Standard precautions (A) are for all clients, contact precautions (C) are for direct contact with the client or their environment, and droplet precautions (D) are for pathogens transmitted through respiratory droplets. Therefore, implementing airborne precautions is crucial to prevent the spread of tuberculosis.
A nurse is planning care for a client who is 12 hr postoperative following a kidney transplant. Which of the following actions should the nurse include in the plan of care?
- A. Check the client's blood pressure every 8 hr.
- B. Assess urine output hourly.
- C. Administer opioids PO.
- D. Monitor for hypokalemia as a manifestation of acute rejection.
Correct Answer: B
Rationale: The correct answer is B: Assess urine output hourly. This is important postoperatively to monitor kidney function and ensure adequate perfusion. Hourly assessment allows for early detection of any changes in urine output, which can indicate complications such as acute kidney injury. Checking blood pressure every 8 hours (Choice A) may be necessary but is less critical in the immediate postoperative period. Administering opioids PO (Choice C) can mask changes in the client's condition and should be avoided until kidney function is stable. Monitoring for hypokalemia (Choice D) is important but not the priority in the immediate postoperative period.
A nurse is planning care for a client who has dementia and a history of wandering. Which of the following actions should the nurse plan to implement?
- A. Move client to a double room.
- B. Use chemical restraints at bedtime.
- C. Use a bed alarm.
- D. Encourage participation in activities that provide excessive stimulation.
Correct Answer: C
Rationale: The correct answer is C: Use a bed alarm. This is the most appropriate action to help prevent the client from wandering and ensure their safety. A bed alarm will alert the nurse when the client tries to get out of bed, allowing for timely intervention. Moving the client to a double room (A) may not necessarily prevent wandering. Using chemical restraints (B) is not recommended due to ethical concerns and potential adverse effects. Encouraging excessive stimulation (D) may increase agitation and wandering behavior.
A nurse is caring for a client who has a small bowel obstruction and an NG tube in place. Which of the following actions should the nurse take?
- A. Maintain low intermittent suction.
- B. Clamp the NG tube every 2 hours.
- C. Remove the NG tube immediately.
- D. Encourage high-fiber foods.
Correct Answer: A
Rationale: The correct answer is A: Maintain low intermittent suction. This is because in a small bowel obstruction, the NG tube helps decompress the bowel by removing gastric contents and relieving pressure. Low intermittent suction helps prevent excessive suction which can cause tissue damage.
Clamping the NG tube every 2 hours (choice B) is incorrect as it will prevent the tube from effectively decompressing the bowel. Removing the NG tube immediately (choice C) is also incorrect as it is needed for decompression. Encouraging high-fiber foods (choice D) is contraindicated as they can worsen the obstruction.
A nurse is assessing a client who is 4 hr postoperative following arterial revascularization of the left femoral artery. Which of the following findings should the nurse report to the provider immediately?
- A. Temperature of 37.9° C (100.2° F)
- B. Pallor in the affected extremity
- C. Bruising around the incisional site
- D. Urine output 150 mL over 4 hr
Correct Answer: B
Rationale: The correct answer is B: Pallor in the affected extremity. Pallor in the affected extremity post arterial revascularization could indicate compromised blood flow, potentially leading to ischemia or thrombosis. This is a critical finding that requires immediate intervention to prevent further complications such as tissue necrosis or limb loss.
Incorrect choices:
A: Temperature elevation may indicate infection, but it is not an immediate concern postoperatively.
C: Bruising around the incisional site is common after surgery and may not require immediate intervention unless there are signs of excessive bleeding.
D: Urine output of 150 mL over 4 hr is within normal limits and not a priority concern in this context.