The palliative care nurse is admitting a client who has metastatic bone cancer and is unable to eat or drink without immediate nausea and vomiting. The client is complaining of pain at 9 on a 0 to 10 pain scale, and the vital signs are: heart rate 99 beats/minute, respirations 38 breaths/minute, oxygen saturation 95%, and blood pressure 110/80 mm Hg. Which Intervention should the nurse implement?

Initiate infusion for an IV fluid bolus.

Administer an IV antiemetic.

Medicate with PRN IV narcotic.

Discourage straining on stool.

Answer and Explanation

The Correct Answer is C

A.   While hydration is important, it's not the most immediate concern when the client is experiencing severe pain and nausea. Addressing the pain should be the priority.
B.   Antiemetics can be helpful for managing nausea and vomiting, but they may not be as effective in addressing the severe pain.
C.   The client's self-reported pain level of 9 on a 0 to 10 scale indicates severe pain, which requires immediate management. IV narcotics are effective for managing severe pain and can be administered quickly to provide immediate relief. Addressing the client's pain can also help to alleviate nausea and vomiting, as pain can exacerbate these symptoms.
D.   This is not relevant to the client's current symptoms of severe pain and nausea.

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Correct Answer is A

Explanation

A.Potassium affects the electrical activity of the heart, and abnormal potassium levels can lead to serious cardiac arrhythmias or other complications. Continuous cardiac monitoring is crucial when administering potassium chloride because it helps detect any arrhythmias or changes in heart function that might be caused by changes in potassium levels.
B.Monitoring urinary output is important because adequate urine output helps assess kidney function and ensures that potassium is being excreted properly. While monitoring urinary output is important, it is secondary to immediate cardiac monitoring during the infusion.
C.Checking the serum potassium level after the infusion is important to confirm that potassium levels have normalized or stayed within the target range. However, this action is not as immediate as continuous cardiac monitoring during the infusion.
D.Regular monitoring of vital signs is important to assess overall client stability and detect any systemic changes. However, obtaining vital signs every 2 hours might not be as critical as continuous cardiac monitoring when administering potassium.

A. Position the package of gauze pads on a sterile field. B. Discard the open bottle of solution before continuing. C. Recap the solution and apply a pair of sterile gloves. D. Obtain all new supplies and start the procedure again.

Correct Answer is A

Explanation

A. Positioning the package of gauze pads on a sterile field is an appropriate action to maintain sterility and ensure that all items used in the procedure remain uncontaminated. However, this step should be considered only if the solution was poured correctly and the sterility of the gauze pads and solution has been maintained.
B. Discarding the open bottle of solution is not necessary unless it has been contaminated. If the solution is still sterile and has not been contaminated (e.g., by touching non-sterile surfaces), there is no need to discard it. The focus should be on ensuring that the solution and all other items remain sterile.
C. Recapping the solution is not recommended because it can lead to contamination. Instead, the solution should be left open or covered with a sterile cap, if provided. Applying sterile gloves is essential for maintaining sterility during the dressing change procedure, but this should be done after ensuring that all supplies and steps are in order.
D. This action would be necessary only if there was a contamination issue or if the sterility of the supplies or solution was compromised. If the sterile technique was not followed properly or there was a risk of contamination, starting the procedure again with new supplies would be appropriate.

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Naxlex Comprehensive Predictor Exams

The client is receiving a liter of 0.9% sodium chloride with potassium chloride (KCI) 30 mEq IV to infuse over 4 hours. Which nursing action has the highest priority for this client?

Correct Answer is A

Explanation

When preparing to change a client's sterile dressing, the nurse pours sterile solution over a package of gauze pads as seen in the picture. Which should the nurse do next?

Correct Answer is A

Explanation

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