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While assessing a patient in the ICU, a nurse observes signs of a weak pulse, quick respiration, acetone breath, and nausea. Which of the following conditions is most likely occurring?
- A. Hypoglycemic patient
- B. Hyperglycemic patient
- C. Cardiac arrest
- D. End-stage renal failure
Correct Answer: B
Rationale: The correct answer is a hyperglycemic patient. The signs described - weak pulse, quick respiration, acetone breath, and nausea - are indicative of hyperglycemia. A hypoglycemic patient would typically present with different signs such as pale skin, sweating, and confusion. Cardiac arrest would manifest with sudden loss of heart function and consciousness, not the signs described. End-stage renal failure would present with symptoms related to kidney dysfunction like edema, fatigue, and changes in urine output, which are not mentioned in the scenario.
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Teaching about the importance of avoiding foods high in potassium is most crucial for which client?
- A. a client receiving diuretic therapy
- B. a client with an ileostomy
- C. a client with metabolic alkalosis
- D. a client with renal disease
Correct Answer: D
Rationale: Clients with renal disease are prone to hyperkalemia due to impaired kidney function, making it crucial for them to avoid foods high in potassium to prevent further complications. Choices A, B, and C are incorrect because clients receiving diuretic therapy, with an ileostomy, or with metabolic alkalosis are at risk of hypokalemia. These individuals should actually consume foods high in potassium to replenish the electrolyte lost through diuresis, ileostomy output, or metabolic alkalosis.
What is an appropriate intervention for the client with suspected genitourinary trauma and visible blood at the urethral meatus?
- A. Insertion of a Foley catheter.
- B. Performing an in-and-out catheter specimen for urinalysis.
- C. Obtaining a voided urine specimen for urinalysis.
- D. Ordering a urinalysis by the physician.
Correct Answer: D
Rationale: When a client presents with suspected genitourinary trauma and visible blood at the urethral meatus, obtaining a voided urine specimen for urinalysis is an appropriate intervention. This helps assess for any urinary tract injuries or abnormalities without further traumatizing the area. Insertion of a Foley catheter (Choice A) should be avoided as it can worsen the existing trauma. Performing an in-and-out catheter specimen (Choice B) involves unnecessary manipulation and can increase the risk of complications. Ordering a urinalysis by the physician (Choice D) may delay the assessment compared to obtaining a direct voided urine specimen.
A pregnant Asian client who is experiencing morning sickness wants to take ginger to relieve the nausea. Which of the following responses by the nurse is appropriate?
- A. "I will call your physician to see if we can start some ginger."?
- B. "We don't use home remedies in this clinic."?
- C. "Herbs are not as effective as regular medicines."?
- D. "Just eat some dry crackers instead."?
Correct Answer: A
Rationale: The correct response is appropriate as it demonstrates cultural sensitivity. Ginger is commonly used to alleviate nausea, particularly in Asian cultures. Contacting the physician to discuss the use of ginger ensures the client's safety and respects their preferences. Choices B and C are incorrect as they disregard the client's request and fail to acknowledge their cultural beliefs. Choice D is incorrect because it does not address the client's desire to use ginger for relief.
A healthcare professional is assessing a patient's right lower extremity. The extremity is warm to touch, red, and swollen. The patient is also running a low fever. Which of the following conditions would be the most likely cause of the patient's condition?
- A. Herpes
- B. Scleroderma
- C. Dermatitis
- D. Cellulitis
Correct Answer: D
Rationale: The patient's presentation of a warm, red, swollen extremity with a low fever is indicative of cellulitis, which is inflammation of cellular tissue. Cellulitis is commonly associated with these symptoms due to a bacterial infection in the skin and underlying tissues. Herpes (Choice A) is a viral infection that typically presents with grouped vesicles, not the warm, red, swollen presentation seen in cellulitis. Scleroderma (Choice B) is a chronic autoimmune condition affecting the skin and connective tissue, presenting differently from the acute symptoms of cellulitis. Dermatitis (Choice C) refers to skin inflammation, which does not typically present with the described symptoms of warmth, redness, swelling, and low fever observed in cellulitis.
A client begins a regimen of chemotherapy. Her platelet count falls to 98,000. Which action is least likely to increase the risk of hemorrhage?
- A. Test all excreta for occult blood.
- B. Use a soft toothbrush or foam cleaner for oral hygiene.
- C. Implement reverse isolation.
- D. Avoid IM injections.
Correct Answer: C
Rationale: The correct answer is to implement reverse isolation. Reverse isolation is a protective measure used to protect patients from infections, not to affect the risk of hemorrhage. Testing all excreta for occult blood (Choice A) is important to monitor for signs of internal bleeding. Using a soft toothbrush or foam cleaner for oral hygiene (Choice B) is recommended to prevent gum bleeding. Avoiding IM injections (Choice D) is crucial to reduce the risk of bleeding in a client with a low platelet count. Therefore, among the given options, implementing reverse isolation is the least likely to increase the risk of hemorrhage.