Nokea
The nurse is caring for assigned clients. The nurse should first check the client with
- A. liver cirrhosis who has a decreased RBC count and is reporting pruritis
- B. pneumonia who has an elevated WBC count and coarse crackles bilaterally
- C. atrial fibrillation who has an irregular heart rate of 122/min and is reporting palpitations
- D. pericarditis who has muffled heart sounds and a decrease in systolic blood pressure of 20 mm Hg with inspiration
Correct Answer: D
Rationale: Pericarditis with paradoxical pulse (D) suggests tamponade, requiring immediate assessment. Atrial fibrillation (C), pneumonia (B), and cirrhosis (A) are less urgent.
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The nurse assesses a client for physiological risk factors for falls. The nurse should conclude that the client is not at risk if which of the following is discovered?
- A. history of dizziness
- B. need for wheelchair due to reduced mobility
- C. weakness and fatigue noted when climbing stairs
- D. intact recent and remote memory
Correct Answer: D
Rationale: Intact recent and remote memory indicates that a client is not at risk for falls. Risk for falls can occur in elder clients, and the nurse should assess each client for the possibility of falls and take appropriate actions.
Which of the following clients is at highest risk for developing Sarcordosis?
- A. A 40-year-old Caucasian with a history of bronchitis atrial tachycardia
- B. A 30-year-old African-American who is pregnant
- C. A 50-year-old Asian male with emphysema
- D. A 60-year-old Hispanic male with cancer
Correct Answer: B
Rationale: Sarcoidosis is most common in African-Americans, particularly women of childbearing age, making the pregnant 30-year-old African-American the highest risk.
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.
While performing an initial assessment on a newborn following a breech delivery, the nurse suspects hip dislocation. Which of the following is most suggestive of the abnormality?
- A. Flexion of lower extremities
- B. Negative Ortolani response
- C. Lengthened leg of affected side
- D. Irregular hip symmetry
Correct Answer: D
Rationale: Irregular hip symmetry. Early assessment of irregular hip symmetry alerts the nurse and the provider to a correctable congenital hip dislocation.
A client with a diagnosis of HPV is at risk for which of the following?
- A. Hodgkin's lymphoma
- B. Cervical cancer
- C. Multiple myeloma
- D. Ovarian cancer
Correct Answer: B
Rationale: The client with HPV is at higher risk for cervical and vaginal cancer related to this STI. She is not at higher risk for the cancers mentioned in answers A, C, and D, so those are incorrect.