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CASAL II – Questions & Accurate Solutions
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CASAL II – Questions & Accurate Solutions
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CASAL II – Questions & Accurate SolutionsA client who takes rifampin tells the nurse, "My urine looks orange." Which
action would the nurse take? Right Ans - check liver enzymes
A client with biliary cirrhosis receives serum albumin therapy. Which action
will the nurse take to evaluate the client's response to therapy? Right Ans -
Weight daily
Rationale
The increased osmotic effect of therapy increases the intravascular volume
and urinary output; weight loss reflects fluid loss. The vital signs will not
change drastically; frequently is a nonspecific timeframe. The urinary output
is measured hourly; half-hour outputs are insignificant in this instance. A
serum, not urine, albumin level is significant; albumin in the urine indicates
kidney dysfunction, not liver dysfunction.
When a client with a history of heart failure arrives for a scheduled clinic
appointment and has gained 6 lb (2.7 kg), which nursing action has the
highest priority? Right Ans - Listen to the client's breath sounds.
Rationale
Because weight gain may indicate fluid retention in this client, the nurse
needs to further assess for fluid overload. Lung congestion associated with
fluid overload would affect oxygenation, and the initial action of the nurse
should be assessment of lung sounds. Checking for lower extremity edema
will also help establish fluid overload, but peripheral edema does not increase
risk for life-threatening complications such as hypoxemia. The health care
provider would be notified after obtaining more assessment data. The pulse
rate will be assessed, but is not directly associated with fluid overload.
A 2-year-old child is admitted to the pediatric unit with a diagnosis of
bacterial meningitis. Which is the most important safety measure for the
nurse to institute immediately after the child has a seizure? Right Ans -
Placing the child in the side-lying position
Rationale
The side-lying position promotes a patent airway; the tongue can move away
from the back of the pharynx, and saliva can flow out of the mouth by gravity.
,Although monitoring vital signs is important, a patent airway is the priority.
The crib sides should have been padded as a part of seizure precautions
before the seizure. If the seizure was unexpected and seizure precautions
were not previously instituted, they should be instituted after the immediate
respiratory and safety needs of the toddler have been met. Suctioning may be
unnecessary; the child should not be left alone while equipment is obtained.
priority intervention for a client in ED with chest pain Right Ans - Assess
airway, breathing, and circulation
The nurse would assess the respiratory status of the client at 2-hour intervals
as a safety priority for which condition affecting the client? Right Ans -
Hypokalemia
Rationale:In case of hypokalemia, the nurse should assess the respiratory
status of the client every 2 hours. In case of hyperkalemia, the nurse should
notify the healthcare team if the heart rate falls below 60 beats per minute or
T waves become spiked. In case of hyponatremia, the nurse should be aware
of muscle weakness in the client and immediately check respiratory
effectiveness. In case of hypernatremia, the nurse should assess the client
hourly for excessive losses of fluid, sodium, or potassium.
Which action would the nurse take first after observing serosanguineous
drainage on the abdominal dressing of a client in the postanesthesia care unit
(PACU) who had an abdominal cholecystectomy? Right Ans - reinforce the
dressing because you are anticipating more drainage
Which condition of a client with hemorrhagic stroke resulting from a motor
bike accident requires immediate attention? Right Ans - Body temperature
of 81.2°F
RATIONALE: Severe hypothermia such as body temperature of 81.2° F must
be immediately corrected by infusing warm fluids and blood. This helps to
prevent hypothermia-related complications. A Glasgow Coma score of 10
needs medium priority since it does indicate immediate danger to the client.
Oxygen saturation of 90 percent indicates a manageable status. Presence of
carotid pulse with blood pressure of 80 mm Hg is acceptable.
, Which action would the nurse perform immediately for a client with
dysrhythmias according to priority? Right Ans - Ensure airway-breathing-
circulation (ABC).
The client with any life-threatening complication such as dysrhythmias should
be assessed for ABCs immediately because the client may suffer with airway
obstruction. Oxygen saturation should be monitored during ongoing
assessments and after providing the client with initial treatment. Intravenous
access should be established after performing initial assessments such as vital
signs. After assessing ABCs in a client with dysrhythmias, the client should be
provided with oxygen via nasal cannula or nonrebreather mask to maintain
oxygen levels.
Once a client admitted with shock secondary to severe gastrointestinal (GI)
bleeding is stabilized, which intervention would the nurse do next? Right
Ans - Take a blood sample for laboratory tests.
Which nursing intervention is the highest priority for an older client with
diabetes mellitus who presents with a large leg ulcer? Right Ans - Teaching
how to transfer from a bed to chair in the least painful manner
Which intervention would the nurse perform first for a clinic client reporting
a productive cough with copious yellow sputum, fever, and chills for the past 2
days? Right Ans - Take the temperature.
Which nursing action is the priority when the nurse discovers in an admission
assessment that a client has a stage 1 pressure ulcer Right Ans - Turn and
reposition the client every 2 hours.
Which nursing action is specific to the plan of care for a client with trigeminal
neuralgia? Right Ans - Monitor intake to prevent dehydration or starvation.
A client with quadriplegia attends tilt table therapy daily and asks why the
angle of the table gradually increases each day. Which response would the
nurse use? Right Ans - The tilt table provides therapeutic weight bearing to
limit loss of calcium from the bones.
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