Nokea
A 62-year-old client admitted to the telemetry unit after an acute myocardial infarction 3 days ago reports that the left calf is very tender and warm to the touch. Which nursing intervention is the priority?
- A. Asking the client how long the leg has been tender and warm
- B. Checking the electrocardiogram for ectopic beats
- C. Obtaining vital signs, including pulse oximetry
- D. Performing a neurovascular check on the lower extremities
Correct Answer: D
Rationale: Tenderness and warmth suggest deep vein thrombosis, so a neurovascular check (D) is the priority to assess for complications. History (A), ECG (B), and vitals (C) are secondary.
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The medical-surgical nurse cares for a group of clients. Which client situations would prompt the nurse to notify the health care provider during the middle of the night? Select all that apply.
- A. Client develops right-sided upper and lower extremity drift
- B. Client found lying unconscious on the floor
- C. Client has order for heparin with surgery planned for the morning
- D. Client has serum sodium of 124 mEq/L (124 mmol/L)
- E. Client refuses a prescribed, routine pain medication
Correct Answer: A,B,C,D
Rationale: Extremity drift (A), unconsciousness (B), heparin before surgery (C), and severe hyponatremia (D) are urgent and require notification. Refusing pain medication (E) is not critical.
A client is admitted with infective endocarditis (IE). Which finding would alert the nurse to a complication of this condition?
- A. dyspnea
- B. heart murmur
- C. macular rash
- D. Hemorrhage
Correct Answer: B
Rationale: Large, soft, rapidly developing vegetations attach to the heart valves. They have a tendency to break off, causing emboli and leaving ulcerations on the valve leaflets. These emboli produce findings of cardiac murmur, fever, anorexia, malaise and neurologic sequelae of emboli.
A client has many delusions. As the nurse helps the client prepare for breakfast the client comments 'Don't waste good food on me. I'm dying from this disease I have.' The appropriate response would be
- A. You need some nutritious food to help you regain your weight.'
- B. None of the laboratory reports show that you have any physical disease.'
- C. Try to eat a little bit, breakfast is the most important meal of the day.'
- D. I know you believe that you have an incurable disease.'
Correct Answer: D
Rationale: This response does not challenge the client’s delusional system and thus forms an alliance by providing reassurance of desire to help the client.
The practical nurse is performing a physical examination with the registered nurse on a 2-year-old with cold symptoms and a fever at home of 101.7 F (38.7 C). Which interventions will enhance the child's cooperation during the examination? Select all that apply.
- A. Allow the child to play with the stethoscope
- B. Begin with the child in the parent's lap
- C. Interact with the parent in a friendly manner
- D. Play with the child using a finger puppet
- E. Start by taking the child's vital signs
Correct Answer: A,B,C,D
Rationale: Playing with the stethoscope (A), starting in the parent's lap (B), friendly interaction (C), and using a puppet (D) reduce anxiety and enhance cooperation. Vital signs (E) may distress the child if done first.
The clinic nurse is reinforcing client teaching about the tiotropium that has been prescribed for chronic obstructive pulmonary disease (COPD). Which statement indicates that the client has a correct understanding of this medication?
- A. A capsule holds the powdered medication that I put in a special inhaler.
- B. I do not need to rinse my mouth out with water after taking tiotropium.
- C. I have been taking tiotropium every time I have difficulty breathing.
- D. Tiotropium helps control my COPD by reducing inflammation in my airway.
Correct Answer: A
Rationale: Tiotropium is a powder in a capsule used with an inhaler (A). Rinsing the mouth (B) is unnecessary, but it's taken daily, not PRN (C), and it's a bronchodilator, not anti-inflammatory (D).