Nokea
Which of the following is a priority intervention for a patient with suspected sepsis?
- A. Administering antibiotics.
- B. Administering IV fluids.
- C. Administering antipyretics.
- D. Monitoring blood cultures.
Correct Answer: D
Rationale: Monitoring blood cultures is a crucial intervention in suspected sepsis because it helps identify the causative organism, which is essential for guiding appropriate antibiotic therapy. Administering antibiotics (Choice A) is important but should be guided by blood culture results. Administering IV fluids (Choice B) is also essential to support hemodynamic stability in sepsis. Administering antipyretics (Choice C) may help reduce fever but is not a priority compared to identifying the causative organism through blood cultures.
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A client who has developed acute kidney injury (AKI) due to an aminoglycoside antibiotic has moved from the oliguric phase to the diuretic phase of AKI. Which parameters are most important for the nurse to plan to carefully monitor?
- A. Side effects of total parenteral nutrition (TPN) and Intralipids.
- B. Uremic irritation of mucous membranes and skin surfaces.
- C. Elevated creatinine and blood urea nitrogen (BUN).
- D. Hypovolemia and electrocardiographic (ECG) changes.
Correct Answer: D
Rationale: During the diuretic phase of acute kidney injury (AKI), monitoring for hypovolemia and electrocardiographic (ECG) changes is crucial. Hypovolemia can occur due to the increased urine output in this phase, potentially leading to dehydration and electrolyte imbalances. Electrolyte imbalances can result in ECG changes, such as arrhythmias, which can be life-threatening. Therefore, careful monitoring of fluid status and ECG findings helps in preventing complications. Choices A, B, and C are not the most crucial parameters to monitor during the diuretic phase of AKI. Side effects of total parenteral nutrition (TPN) and Intralipids, uremic irritation of mucous membranes and skin surfaces, and elevated creatinine and blood urea nitrogen (BUN) are important considerations in other phases of AKI or in other conditions, but they are not the primary focus during the diuretic phase when hypovolemia and ECG changes take precedence.
A client with Diabetes Insipidus (DI) is being cared for by a nurse. Which data warrants the most immediate intervention by the nurse?
- A. Serum sodium of 185 mEq/L (185 mmol/L)
- B. Dry skin with poor skin turgor
- C. Apical rate of 110 beats per minute
- D. Polyuria and excessive thirst
Correct Answer: A
Rationale: A serum sodium level of 185 mEq/L (185 mmol/L) is dangerously high and indicates severe dehydration, requiring immediate intervention to prevent neurological damage. The other options are not as critical as high serum sodium levels, which can lead to serious complications such as seizures, coma, and death if not promptly addressed. Dry skin with poor skin turgor and polyuria with excessive thirst are common findings in clients with Diabetes Insipidus and should be managed but do not pose an immediate threat to the client's life. An apical heart rate of 110 beats per minute may indicate tachycardia, which could be related to dehydration but is not as urgent as addressing the severe hypernatremia.
An adult client is admitted with flank pain and is diagnosed with acute pyelonephritis. What is the priority nursing action?
- A. Monitor hemoglobin and hematocrit
- B. Encourage turning and deep breathing
- C. Administer IV antibiotics as prescribed
- D. Auscultate for presence of bowel sounds
Correct Answer: C
Rationale: The priority nursing action for a client diagnosed with acute pyelonephritis is to administer IV antibiotics as prescribed. Acute pyelonephritis is a serious kidney infection that requires prompt antibiotic therapy to prevent systemic complications and worsening of the infection. While monitoring hemoglobin and hematocrit (Choice A) is important, it is not the priority in the acute phase of infection. Encouraging turning and deep breathing (Choice B) and auscultating for bowel sounds (Choice D) are relevant aspects of care but do not take precedence over initiating antibiotic treatment to address the infection promptly.
After a session of hemodialysis, the nurse should monitor the client for which of the following complications of hemodialysis?
- A. Hyperkalemia.
- B. Hypotension.
- C. Infection.
- D. Fever.
Correct Answer: B
Rationale: The correct answer is 'B: Hypotension.' Hypotension is a common complication of hemodialysis because fluid removal during the process can lead to a drop in blood pressure. The nurse should closely monitor the client for signs of hypotension such as dizziness, lightheadedness, or a decrease in blood pressure readings. Choice 'A: Hyperkalemia' is incorrect because hemodialysis actually helps lower potassium levels by removing excess potassium from the blood. Choice 'C: Infection' is incorrect as it is not a direct complication of hemodialysis but rather a risk associated with invasive procedures. Choice 'D: Fever' is incorrect as fever is not a typical immediate post-hemodialysis complication unless an underlying infection is present.
A client with Herpes Zoster (shingles) on the thorax tells the nurse about having difficulty sleeping. What is the probable cause of this problem?
- A. Frequent cough
- B. Pain
- C. Nocturia
- D. Dyspnea
Correct Answer: B
Rationale: The correct answer is B: Pain. Pain is a common and significant symptom of Herpes Zoster (shingles) that can result in difficulty sleeping. The pain associated with shingles can be intense and persistent, making it challenging for the client to find a comfortable position to sleep. Nocturia (choice C), which is excessive urination during the night, is not directly related to difficulty sleeping in this context. While both frequent cough (choice A) and dyspnea (choice D) can cause sleep disturbances, in a client with Herpes Zoster on the thorax, pain is the most probable cause of sleep difficulty.