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Which of these clients, all of whom have the findings of a board-like abdomen, would the nurse suggest that the provider examine first?
- A. An elderly client who stated, 'My awful pain in my right side suddenly stopped about 3 hours ago.'
- B. A pregnant woman of 8 weeks newly diagnosed with an ectopic pregnancy
- C. A middle-aged client admitted with diverticulitis who has taken only clear liquids for the past week
- D. A teenager with a history of falling off a bicycle without hitting the handle bars
Correct Answer: A
Rationale: An elderly client who stated, 'My awful pain in my right side suddenly stopped about 3 hours ago.' This client has the highest risk for hypovolemic and septic shock since the appendix has most likely ruptured, based on the history of the pain suddenly stopping over three hours ago. Elderly clients have less functional reserve for the body to cope with shock and infection over long periods. The others are at risk for shock also, however given that they fall in younger age groups, they would more likely be able to tolerate an imbalance in circulation. A common complication of falling off a bicycle is hitting the handle bars in the upper abdomen often on the left, resulting in a ruptured spleen.
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The nurse is talking with the parent of a 5-year-old client who is receiving morphine for pain. Which of the following statements by the parent would be a priority to follow up?
- A. My child may act aggressively when experiencing pain.
- B. I am concerned that my child thinks the pain is punishment.
- C. The FACES pain scale can be used to monitor my child's pain level.
- D. My child is playing and therefore does not need any pain medication now.
Correct Answer: D
Rationale: Assuming a playing child has no pain (D) is incorrect, as children may play despite pain. This requires follow-up to ensure adequate pain management. Aggression (A) and feeling punished (B) are valid concerns but less urgent. Using the FACES scale (C) is appropriate.
The nurse is preparing to administer medications to a client with acute decompensated heart failure. Which of the following medications should the nurse hold for clarification prior to administering?
- A. atorvastatin
- B. enoxaparin
- C. furosemide
- D. metoprolol
Correct Answer: D
Rationale: Metoprolol (D) may worsen acute decompensated heart failure by reducing cardiac output, requiring clarification. Furosemide (C) treats fluid overload, enoxaparin (B) prevents thrombosis, and atorvastatin (A) manages lipids.
A client is being discharged after having a stent placed in the left anterior descending coronary artery. The client is prescribed clopidogrel. Which client data obtained by the nurse would be concerning in relation to this new medication?
- A. Blood pressure of 140/84 mm Hg
- B. Heart rate of 98/min
- C. Platelet count of 200,000/mm^3 (200 x 10^9/L)
- D. Report of Ginkgo biloba use
- E. Report of peptic ulcer disease
Correct Answer: D,E
Rationale: Ginkgo biloba (D) and peptic ulcer disease (E) increase bleeding risk with clopidogrel, requiring caution. Blood pressure (A), heart rate (B), and platelet count (C) are within normal limits.
The nurse has delegated the task of taking the temperature of a client with a new tympanic thermometer to a certified nursing assistant. The nursing assistant says, 'This looks easy. I am good at figuring things out.' What is the nurse's responsibility?
- A. Allow the nursing assistant to proceed.
- B. Assign the task to another nursing assistant.
- C. Ask another nursing assistant to demonstrate this task to the nursing assistant.
- D. Demonstrate the proper use of the thermometer and observe the nursing assistant.
Correct Answer: D
Rationale: Demonstrating and observing ensures the CNA uses the tympanic thermometer correctly, maintaining accuracy and safety.
The nurse is reinforcing teaching to the parents of a hospitalized 3-month-old about separation anxiety. The nurse notices that the parents still seem concerned about leaving the infant while they work. Which statement by one of the parents indicates that the teaching has been effective?
- A. At this age, my baby will not cry because we are leaving.
- B. I know my baby will feel abandoned when we leave.
- C. My baby is too young to sense my anxiety about leaving.
- D. My baby understands that we will return later in the day.
Correct Answer: C
Rationale: Infants at 3 months (C) do not yet exhibit separation anxiety and cannot sense parental anxiety. Crying (A), feeling abandoned (B), and understanding return (D) occur later in development.