Nokea
A 78-year-old client with a history of diabetes mellitus type 2, GERD, and hypertension is hospitalized with pneumonia and rings the call bell at 11 PM, complaining of being unable to sleep and having 'indigestion' and 'heartburn.' Which of the following initial interventions is most indicated?
- A. Administer antacid per prn order.
- B. Administer acetaminophen per prn order.
- C. Administer hypnotic per prn order.
- D. Assess cardiac and respiratory status.
Correct Answer: D
Rationale: In an elderly client with comorbidities, indigestion and heartburn may indicate a cardiac event, so assessing cardiac and respiratory status (D) is the priority. Administering medications (A, B, C) is secondary.
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A client with emphysema has been receiving oxygen at 3 L per minute by nasal cannula. The nurse knows that the goal of the client's oxygen therapy is achieved when the client's PaO2 reading is:
- A. 50-60 mm Hg
- B. 70-80 mm Hg
- C. 80-90 mm Hg
- D. 90-98 mm Hg
Correct Answer: B
Rationale: For clients with emphysema, a PaO2 of 70-80 mm Hg indicates adequate oxygenation without suppressing the respiratory drive.
A client taking the drug disulfiram (Antabuse) is admitted to the ER. Which clinical manifestations are most indicative of recent alcohol ingestion?
- A. Vomiting, heart rate 120, chest pain
- B. Nausea, mild headache, bradycardia
- C. Respirations 16, heart rate 62, diarrhea
- D. Temp 101°F, tachycardia, respirations 20
Correct Answer: A
Rationale: Disulfiram causes a severe reaction with alcohol, including vomiting, tachycardia (HR 120), and chest pain due to acetaldehyde accumulation, making these symptoms most indicative.
A 3-year-old child had a PPD skin test 2 days ago. When the mother brings the child back to the clinic to have the nurse check the results, the nurse notes a 10 mm area of induration. This is considered
- A. an inconclusive skin test.
- B. a positive skin test.
- C. a negative skin test.
- D. too early to determine the results.
Correct Answer: B
Rationale: A 10 mm induration 48-72 hours post-PPD is positive in children, indicating TB exposure, especially in high-risk groups.
A woman is admitted to the labor and delivery unit in a sickle cell crisis. Which of the following nursing actions is the HIGHEST priority?
- A. Administer oxygen.
- B. Turn her to the right side.
- C. Provide adequate hydration.
- D. Start antibiotics.
Correct Answer: C
Rationale: adequate hydration is a priority for any client with sickle cell crisis
A new graduate nurse completes her first full shift with her preceptor. It was a long, overwhelming day and the new nurse takes a deep breath and says to herself, 'You can do this! Nursing will be a challenge but you are up for it and tomorrow is a new day.' This type of communication is
- A. intrapersonal.
- B. horizontal.
- C. interpersonal.
- D. vertical.
Correct Answer: A
Rationale: Intrapersonal communication is self-talk, as the nurse reflects and motivates herself.