Nokea
A client admitted four days ago for treatment of alcohol dependence is now displaying the following symptoms: slurred speech, ataxia, uncoordinated movements, and headache. Which of the following nursing actions should be taken FIRST?
- A. Observe the client for eight hours to collect additional data.
- B. Perform a complete physical assessment.
- C. Collect a urine specimen for a drug screen.
- D. Encourage the client to talk about whatever is bothering him.
Correct Answer: B
Rationale: best way to identify possible physical complications of alcohol dependence is through a complete physical assessment
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A client with internal radiation.
Which of the following actions, if taken by the nurse, is MOST important?
- A. Restrict visitors who may have an upper respiratory infection.
- B. Assign only male caregivers to the client.
- C. Plan nursing activities to decrease nurse exposure.
- D. Wear a lead-lined apron whenever delivering client care.
Correct Answer: C
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) all visitors are restricted with regard to the distance they should be from the client (2) not relevant to the situation (3) correct-principles for radiation therapy are time, distance, shielding; nurse should decrease the time spent in close proximity to the client (4) appropriate shielding (lead aprons) is to be used when the nurse has to spend any length of time at a close distance, not just for routine care
The physician orders indomethacin (Indocin) 25 mg PO bid for a 34-year-old woman. It would be most important for the nurse to make which of the following statements?
- A. Take this medication with food.
- B. Take this medication one hour before meals.
- C. Take this medication one hour after meals.
- D. Take this medication with orange juice.
Correct Answer: A
Rationale: reduces GI upset
The nurse takes a history from a woman in the prenatal clinic. The nurse identifies that which of the following pregnant women is MOST likely to have an Rh-incompatibility problem?
- A. An Rh-positive woman pregnant for the third time who conceived with an Rh-negative man and never has received RhoGAM.
- B. An Rh-negative woman who conceived with an Rh-positive man who has Rh antibodies.
- C. An Rh-positive woman who previously aborted a fetus at 12 weeks gestation and did not receive RhoGAM and now conceived with an Rh-positive man.
- D. An Rh-negative woman who never received RhoGAM and now conceived with an Rh-negative man.
Correct Answer: B
Rationale: Rh-positive dominant, fetus will be Rh-positive, Rh antibodies from the mother will break down fetus's blood cells
A client is admitted to the unit with pregnancy-induced hypertension (PIH).
Which of the following actions is the priority nursing action?
- A. Start an IV.
- B. Obtain the vital signs.
- C. Administer magnesium sulfate.
- D. Notify the lab to draw blood.
Correct Answer: B
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes. (1) implementation, not a priority action (2) correct-assessment, important to do a baseline assessment in order to successfully evaluate the treatment (3) implementation, not a priority action (4) implementation, not a priority action
The nurse plans care for a 25-year-old woman immediately after a cesarean section. Which of the following nursing goals is MOST important?
- A. Prevent infection.
- B. Prevent fluid and electrolyte imbalances.
- C. Provide for pain management.
- D. Prevent hazards of immobility.
Correct Answer: B
Rationale: hemorrhage and shock most life-threatening conditions that occur after surgery