How should a nurse remove a gown from a client with an intravenous line?

Correct Answer: C

Rationale: Correct Answer: C Rationale: By threading the IV bag and tubing through the gown sleeve, the nurse ensures that the client's IV line remains intact and secure. This method minimizes the risk of dislodging the IV line or causing discomfort to the client. It also allows for a smooth removal of the gown without compromising the IV line. Summary: A: Disconnecting tubing near the client can lead to accidental disconnection of the IV line. B: Cutting the gown with scissors is unnecessary and poses a risk of damaging the IV line. D: Disconnecting the tubing at the IV container may result in spillage of IV fluids and potential contamination.

Correct Answer: A

Rationale: The correct answer is A: Administer glucose. Hypoglycemia is low blood sugar, and administering glucose rapidly raises blood sugar levels to restore normal function. Glucagon (choice B) is used for severe hypoglycemia when the individual cannot consume oral glucose. Insulin (choice C) lowers blood sugar levels and is contraindicated in hypoglycemia. Corticosteroids (choice D) can worsen hypoglycemia by affecting glucose metabolism. Administering glucose is the most direct and effective intervention for hypoglycemia.

Correct Answer: B

Rationale: The correct answer is B: Monitor abdominal pain. This is the priority assessment for a client with acute pancreatitis because it helps determine the severity of the condition and guides the treatment plan. Abdominal pain is a key symptom of pancreatitis and monitoring its intensity, location, and changes over time is crucial. Assessing vital signs (choice A) is important but secondary to monitoring pain. Monitoring serum amylase levels (choice C) is relevant for diagnosis but not immediate priority. Performing a CT scan (choice D) may be necessary later for further evaluation but is not the initial priority in managing acute pancreatitis.

Correct Answer: B

Rationale: The correct hand position for performing chest vibration is to spread the fingers. This allows for a larger surface area of contact with the chest, promoting effective transmission of vibrations to loosen chest secretions. Flattening the hands would reduce the effectiveness of the vibrations by limiting contact area. Cupping the hands creates a smaller contact area and may concentrate the pressure too much in one spot, potentially causing discomfort or injury. Therefore, spreading the fingers is the optimal hand position for chest vibration technique.

Correct Answer: A

Rationale: The correct answer is A: Administer antiepileptics. Administering antiepileptics is the priority nursing action for a client with a history of seizures to prevent seizure recurrence. Antiepileptics help control and manage seizure activity effectively. Monitoring vital signs (B) and placing the client in a lateral position (C) are important actions during a seizure but are not the priority over administering antiepileptics. Providing seizure precautions (D) is also important but does not directly address the immediate need of administering antiepileptics to prevent a seizure.

Correct Answer: D

Rationale: The correct answer is D: cirrhosis. Cirrhosis leads to impaired liver function, causing the liver to be unable to effectively metabolize ammonia, leading to high ammonia levels in the blood. Renal failure (choice A) is associated with high creatinine levels, not ammonia. Psoriasis (choice B) is a skin condition unrelated to ammonia levels. Lupus (choice C) is an autoimmune disease affecting various organs, not directly linked to high ammonia levels. In summary, cirrhosis is the only condition among the options that directly impacts liver function and can lead to high ammonia levels in the blood.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. After a craniotomy, the client may experience decreased oxygen levels due to the surgical procedure, anesthesia, or potential complications. Administering oxygen helps ensure adequate oxygenation to the brain and tissues. Placing the client in a supine or Trendelenburg position can increase intracranial pressure, which is contraindicated post-craniotomy. Monitoring for arrhythmias is important, but ensuring oxygenation takes precedence as hypoxia can have immediate detrimental effects on brain function.

Correct Answer: C

Rationale: The correct answer is C: Objective. Objective data in a physical assessment refers to measurable and observable information obtained through physical examination, laboratory tests, and diagnostic procedures. This type of data is crucial as it is based on facts and can be quantified. Subjective data (A) is based on the patient's feelings and experiences, while patient-centered (B) refers to care that is tailored to the individual's preferences. Diagnostic (D) data refers to information obtained through tests to determine a specific condition, which is different from the general data collected during a physical assessment.

Correct Answer: A

Rationale: The correct answer is A: Administer anticoagulants. Anticoagulants help prevent the blood clot from getting larger and reduce the risk of it breaking loose and causing a pulmonary embolism. Other choices are incorrect because B: Monitoring vital signs alone does not treat the DVT, C: Providing bed rest can increase the risk of complications like pulmonary embolism, and D: Administering fibrinolytics is not the first-line treatment for DVT.