Exhibits

A nurse in an emergency department is assessing a client who has major depressive disorder. Which of the following actions should the nurse take first? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)

Administer ondansetron to the client for nausea.

Obtain a blood glucose level.

Implement seizure precautions for the client.

Obtain the client's weight

Answer and Explanation

The Correct Answer is C

Rationale:

A. Administer ondansetron to the client for nausea: Treating nausea is important for comfort, but it does not address the most urgent risk. Nausea is not immediately life-threatening compared with potential complications from medication overdose.

B. Obtain a blood glucose level: Checking blood glucose can provide useful information, but there is no indication of hypoglycemia or diabetes-related crisis in this scenario. It is not the priority action.

C. Implement seizure precautions for the client: The client has been doubling the bupropion dose, which significantly increases the risk of seizures, especially at doses above the prescribed maximum. Seizure precautions address an immediate life-threatening risk and should be the first intervention.

D. Obtain the client's weight: Monitoring weight is important for assessing nutritional status and the severity of depression, but it is not an immediate safety concern. Life-threatening risks, such as seizures, take priority.

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Correct Answer is B

Explanation

Rationale:

A. Position the child at a 10° to 20° angle after feeding: This angle is too low to effectively reduce the risk of aspiration. The child should remain in at least a 30° to 45° upright position during and after feeding for optimal safety.

B. Measure the tubing from the nose to the distal port: Correct placement measurement involves determining the appropriate tube length from the tip of the nose to the earlobe and then to the xiphoid process. Measuring to the distal port ensures accurate placement for safe feeding.

C. Warm the formula in the microwave: Microwaving can create uneven heating and hot spots that may burn the gastrointestinal mucosa. Formula should be warmed by placing the container in warm water and checking the temperature before administration.

D. Complete the feeding in 5 min: Rapid feeding increases the risk of nausea, vomiting, and aspiration. Feedings should be administered slowly over the recommended time frame to allow for tolerance and digestion.

A. Maintain the irrigation solution rate. B. Warm the irrigation solution. C. Perform the Credé's maneuver. D. Replace the indwelling urinary catheter.

Correct Answer is A

Explanation

Rationale:

A. Maintain the irrigation solution rate: Pink-tinged urine is expected in the early hours after a TURP due to residual bleeding from the surgical site. The nurse should continue the current irrigation rate to prevent clot formation and maintain catheter patency.

B. Warm the irrigation solution: Warming the solution is not required for bladder irrigation and does not address the normal postoperative finding of pink-tinged urine. It also does not play a role in preventing clot formation.

C. Perform the Credé's maneuver: This technique, involving manual bladder compression, is not appropriate for a client with a continuous bladder irrigation and indwelling catheter in place. It could cause injury or disrupt the surgical site.

D. Replace the indwelling urinary catheter: There is no indication of catheter blockage or malfunction in this scenario. Replacing the catheter unnecessarily increases infection risk and could damage the urethra or surgical area.

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Exhibits A nurse in an emergency department is assessing a client who has major depressive disorder. Which of the following actions should the nurse take first? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)

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Exhibits

A nurse in an emergency department is assessing a client who has major depressive disorder. Which of the following actions should the nurse take first? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)