Nokea
Which of the following should the nurse identify as a priority nursing diagnosis for an infant with intussusception?
- A. Deficient fluid volume
- B. Impaired skin integrity
- C. Acute pain
- D. Impaired gas exchange
Correct Answer: C
Rationale: Acute pain is the priority nursing diagnosis for an infant with intussusception due to bowel obstruction causing severe abdominal pain. Fluid volume and gas exchange may be concerns but are secondary.
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The nurse assesses a client and notes that he has a weak, irregular pulse, as well as soft, flabby muscles. The nurse should assess the client further for:
- A. Hypercalcemia.
- B. Hypernatremia.
- C. Hypokalemia.
- D. Hypomagnesemia.
Correct Answer: C
Rationale: Weak, irregular pulse and flabby muscles are signs of hypokalemia, which affects muscle and cardiac function. The other conditions present differently.
During the admission interview, an adult client reveals that, as a child, she was sexually abused by her uncle and a male cousin. She reports that she cuts the skin of her arms, legs, and abdomen. In addition to having the client sign a no-harm contract, which nursing intervention is most important?
- A. Assist the client with finding safe ways to express her anger.
- B. Talk with the client about confronting her uncle and cousin directly.
- C. Defer talking about the abuse to prevent further self-mutilation.
- D. Discuss the possibility of the client suing her relatives for their abuse.
Correct Answer: A
Rationale: Helping the client find safe ways to express anger addresses the self-harm behavior therapeutically, promoting coping skills and safety.
The nurse is caring for a client with a tracheostomy. Which of the following interventions should be included in the plan of care? Select all that apply.
- A. Suction the tracheostomy as needed.
- B. Clean the inner cannula daily.
- C. Change the tracheostomy ties weekly.
- D. Monitor for signs of skin breakdown.
- E. Keep the tracheostomy tube uncuffed.
Correct Answer: A, B, C, D
Rationale: Suctioning, cleaning the cannula, changing ties, and monitoring for skin breakdown are essential for tracheostomy care. Cuffed tubes are used in specific cases.
A 70-year-old, previously well client asks the nurse, 'I notice I have tremors. Is this just normal for my age?' The best response for the nurse to make is which of the following?
- A. I wouldn't be worried because this is common with aging
- B. You should report this to the physician because it may indicate a problem
- C. You should drink orange juice when this occurs
- D. You should have your blood pressure checked when this occurs
Correct Answer: B
Rationale: Tremors in a 70-year-old are not necessarily normal and may indicate conditions like Parkinson's or medication side effects, requiring physician evaluation. Orange juice or blood pressure checks are not directly relevant.
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. Serum sodium.
- C. Blood urea nitrogen.
- D. Blood glucose.
Correct Answer: D
Rationale: TPN contains high glucose concentrations, requiring close monitoring of blood glucose to prevent hyperglycemia.