Nokea
A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?
- A. A client who has epidural analgesia and weakness in the lower extremities
- B. A client who has a hip fracture and a new onset of tachypnea
- C. A client who has sinus arrhythmia and is receiving cardiac monitoring
- D. A client who has diabetes mellitus and an HbA1c of 6.8%
Correct Answer: B
Rationale: The correct answer is B. The nurse should assess the client with a hip fracture and new onset of tachypnea first. Tachypnea in this client could indicate a potential complication such as a pulmonary embolism, which is a life-threatening condition requiring immediate intervention. Assessing this client first allows for prompt identification and management of any emergent issues. Clients with epidural analgesia and lower extremity weakness (choice A) may indicate a neurological concern but are not as urgent as tachypnea in a client with a hip fracture. Sinus arrhythmia with cardiac monitoring (choice C) and diabetes mellitus with an HbA1c of 6.8% (choice D) do not present immediate life-threatening situations that require immediate assessment compared to the client with a hip fracture and tachypnea.
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Which of the following instructions should the nurse include in the teaching?
- A. Place tongue on the mouthpiece of the meter
- B. Maintain a semi-Fowler's position during testing
- C. Record the average of the readings.
- D. Blow into the meter as hard and quickly as possible.
Correct Answer: D
Rationale: The correct answer is D because blowing into the meter as hard and quickly as possible ensures accurate lung function test results. This instruction ensures a consistent and forceful flow of air, which is crucial for reliable readings. Option A is incorrect because the tongue should not be placed on the mouthpiece, as this can affect the accuracy of the test. Option B is incorrect as maintaining a semi-Fowler's position is not necessary for this test. Option C is incorrect because recording the average of the readings is not a step in the actual testing process.
Which of the following findings places the client at risk if he receives alteplase?
- A. Family history of malignant hypertension
- B. Hip arthroplasty 1 week ago
- C. Chronic obstructive pulmonary disease
- D. Acute renal failure 6 months ago
Correct Answer: B
Rationale: Recent surgeries increase bleeding risks with thrombolytics.
Which of the following examples should the nurse include in the teaching as an example of malpractice?
- A. Documenting communication with a provider in the progress notes of the client's medical record
- B. Placing a yellow bracelet on a client who is at risk for falls
- C. Leaving a nasogastric tube clamped after administering oral medication
- D. Administering potassium via IV bolus
Correct Answer: C
Rationale: The correct answer is C because leaving a nasogastric tube clamped after administering oral medication is an example of malpractice. This action can lead to obstruction and potential harm to the client. Documenting communication (A) is a standard practice to ensure accurate record-keeping. Placing a yellow bracelet (B) is a safety measure. Administering potassium via IV bolus (D) is within the scope of practice if done correctly.
The nurse anticipates the client will likely require-------as evidenced by the client’s---------
- A. temperature
- B. stool test results
- C. respiratory rate
- D. an endoscopy
- E. an antifungal prescription
- F. oxygen via nonrebreather mask
Correct Answer: B,D
Rationale: The correct answers are B (stool test results) and D (an endoscopy). The nurse anticipates the client will likely require a stool test based on gastrointestinal symptoms, such as abdominal pain or blood in stool. Stool test results can help diagnose gastrointestinal issues. Additionally, the nurse may anticipate the need for an endoscopy to further investigate gastrointestinal symptoms, like persistent reflux or difficulty swallowing. Choices A, C, E, and F are less likely as they are not directly related to gastrointestinal issues. Choice E (antifungal prescription) may be relevant in case of fungal infection, but gastrointestinal symptoms would not typically prompt this. Choice F (oxygen via nonrebreather mask) is more related to respiratory issues.
A nurse is caring for a client who has given informed consent for electroconvulsive therapy. Just before the procedure, the client tells the nurse she is considering not going forward with the treatment. Which of the following statements by the nurse is appropriate?
- A. Most people who have this procedure feel better following the treatment.
- B. Your doctor wouldn't have ordered this treatment unless it was necessary.â€
- C. It's okay to be nervous before this treatment.
- D. You don't have to go through with the treatment.
Correct Answer: D
Rationale: Rationale: Option D is correct because it respects the client's autonomy and right to make decisions about their treatment. The client has the right to refuse treatment, even after giving initial consent. It is important for the nurse to support the client's decision without coercion.
Summary:
A: Incorrect. This statement does not address the client's current decision to refuse treatment.
B: Incorrect. This statement undermines the client's autonomy by implying they should follow the doctor's orders.
C: Incorrect. While acknowledging the client's feelings is important, it does not address the client's decision to refuse treatment.
D: Correct. Respects the client's autonomy and decision-making.
E, F, G: Not applicable.