A client with persistent low back pain has received a prescription for an electronic stimulator (TENS) unit. After the nurse applies the electrodes and turns on the power, the client reports feeling a tingling sensation. How should the nurse respond?

Remove electrodes and observe for skin redness.

Decrease the strength of the electrical signals.

Check the amount of gel coating on the electrodes.

Determine if the sensation feels uncomfortable.

Answer and Explanation

The Correct Answer is D

A)   Incorrect - Skin redness might indicate irritation, but the initial focus should be on the client's sensation.
B)   Incorrect - Decreasing the strength of the electrical signals might be premature if the sensation is normal.
C)   Incorrect - The amount of gel coating on the electrodes might not be the primary issue if the client is feeling a tingling sensation.
D)   Correct- A tingling sensation is normal and expected when using a TENS unit, and it does not indicate any harm or damage to the skin or nerves. However, the sensation should not be painful or unpleasant for the client, and the nurse should adjust the intensity of the electrical signals accordingly.

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Correct Answer is A

Explanation

Septic shock is a life-threatening condition characterized by a severe infection that leads to systemic inflammation, organ dysfunction, and low blood pressure. Maintaining strict intake and output monitoring is essential to assess the client's fluid balance and response to interventions. It allows the nurse to closely monitor the client's urine output, which is a crucial indicator of renal perfusion and overall organ function.

Monitoring urine output helps the nurse assess the adequacy of tissue perfusion and the client's response to fluid resuscitation. A decrease in urine output can be an early sign of worsening organ dysfunction and a need for further interventions.

While assessing the warmth of extremities is important for evaluating peripheral perfusion, maintaining strict intake and output monitoring takes priority as it provides more comprehensive information about the client's overall fluid status.

Raising the head of the bed 45 degrees (semi-Fowler's position) can help optimize respiratory function and reduce the risk of aspiration, but it is not the most important intervention in this case.

Monitoring blood glucose levels is important, as hyperglycemia can be associated with sepsis. However, in the context of septic shock, maintaining strict intake and output monitoring takes precedence as it directly assesses the client's fluid balance and response to interventions.

It's crucial to note that the management of septic shock requires a multidisciplinary approach, and other interventions, such as administering appropriate antibiotics, initiating fluid resuscitation, and addressing the underlying source of infection, should also be implemented in a timely manner.

A. Take the child's pulse B. Place a cervical collar on the client C. Look for any open wounds D. Call child protective services E. Determine if the child's airway is clear F. Start a peripheral intravenous line

Correct Answer is ["A","B","C","E"]

Explanation

A) Correct- Assessing the child's pulse helps determine their cardiac status and whether they have a detectable heartbeat. This information is essential for deciding the appropriate interventions.
B) Correct- Placing a cervical collar is necessary if there is any suspicion of cervical spine injury due to the fall or submersion. This action helps stabilize the neck and prevent further damage to the spine.
C) Correct- Checking for open wounds is important to assess for potential sources of bleeding or infection that may require immediate attention.
D) Incorrect- While child safety is important, the immediate priority in this situation is assessing and stabilizing the child's medical condition. Child protective services may be involved later if there are concerns about the circumstances surrounding the incident.
E) Correct- Assessing the airway is of utmost importance to ensure that the child can breathe. In cases of near-drowning, ensuring a clear airway is crucial for oxygenation.
F) Incorrect- While establishing intravenous access may be important for certain interventions, it is not one of the immediate priorities in this situation. Ensuring the child's airway, breathing, and circulation take precedence.

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A client with persistent low back pain has received a prescription for an electronic stimulator (TENS) unit. After the nurse applies the electrodes and turns on the power, the client reports feeling a tingling sensation. How should the nurse respond?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Review H and P and nurse's notes. What are the first four actions that the nurse should take?

Correct Answer is ["A","B","C","E"]

Explanation

The nurse is administering multiple prescribed vaccines to a toddler. Which strategy should the nurse prioritize to reduce the duration of pain?

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