Nokea
A 2-year-old child seen in the emergency department is dehydrated and malnourished. The child’s parent reports that the child has had diarrhea for the past 2 weeks. Which observation is of most concern to the nurse?
- A. The parent cannot stay at the hospital due to potential job loss if late for work
- B. The parent does not seem to be concerned about the child’s condition
- C. The parent is single
- D. The parent left a 3-year-old and a 5-year-old in the care of a 9-year-old
Correct Answer: D
Rationale: Leaving young children in the care of a 9-year-old poses significant safety risks, indicating neglect and requiring immediate intervention. Job constraints, lack of concern, and single status are concerning but less immediately dangerous.
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The nurse is caring for a client who had thoracic surgery yesterday and has a chest tube attached to water seal drainage. The client's family asks why he has to have a chest tube. What should the nurse include in the response?
- A. The chest tube allows air to enter the thoracic cavity to equalize pressures in the lung.
- B. The chest tube removes air from the pleural cavity and promotes reexpansion of the lung.
- C. The chest tube increases the amount of oxygen available to the lungs.
- D. The chest tube will help the wound heal faster and reduce scarring.
Correct Answer: B
Rationale: Chest tubes remove air/fluid from the pleural cavity, allowing lung reexpansion post-thoracic surgery. Other options misrepresent the tube's function.
The home health nurse is caring for an 85-year-old client. It would require immediate follow-up if the client is reporting
- A. a painful red area on the buttocks
- B. new onset of dependent edema of the feet
- C. progressive loss of central vision
- D. no memory of activities performed yesterday
Correct Answer: A
Rationale: A painful red area on the buttocks suggests a pressure injury, requiring immediate intervention to prevent worsening. Edema, vision loss, and memory issues are concerning but less urgent.
The nurse is reinforcing discharge teaching for a client who had aortic valve replacement with a mechanical heart valve. Which statement by the client indicates that teaching has been effective?
- A. I'm glad that I can continue taking my Ginkgo biloba.
- B. I will increase my intake of leafy green vegetables
- C. I will start applying vitamin E to my chest incision after showering
- D. I will shave with an electric razor from now on
Correct Answer: D
Rationale: Mechanical prosthetic valves are more durable than biological valves but require long-term anticoagulation therapy due to the increased risk of thromboembolism. The client should be taught ways to reduce the risk of bleeding.
A woman comes into the labor suite stating that her water has broken and she is in labor. Which symptoms point to the possible presence of placenta previa?
- A. Sudden knife-like pain in the lower abdomen accompanied by profuse vaginal bleeding
- B. Dark red vaginal discharge that started after she saw the physician this morning
- C. Bright red painless vaginal bleeding
- D. A tender rigid uterine wall and abdomen with no vaginal bleeding evident
Correct Answer: C
Rationale: Placenta previa typically presents with bright red, painless vaginal bleeding due to the placenta covering the cervix, distinguishing it from abruptio placentae or other conditions.
A nurse assigns a task to unlicensed assistive personnel. They state, 'We can’t do that.' Which is the best initial response for the nurse to make?
- A. Ask the unlicensed assistive personnel (UAP) the reason for the response
- B. Do the task, but discuss the UAP’s response with the manager
- C. Ignore the UAP’s initial response and repeat the assigned request
- D. Remind the UAP of the importance of teamwork
Correct Answer: A
Rationale: Asking the reason clarifies whether the refusal is due to scope, training, or other issues, promoting collaboration. Performing the task, ignoring, or lecturing avoids addressing the root cause.