Nokea
A client comes to the emergency department with diplopia and recent onset of nausea. Which statement by the client would indicate to the nurse that this is an emergency?
- A. I am very tired, and it's hard for me to keep my eyes open.'
- B. I don't feel good, and I want to be seen.'
- C. I have not taken my blood pressure medicine in over a week.'
- D. I have the worst headache I've ever had in my life.'
Correct Answer: D
Rationale: A severe headache described as the worst ever with diplopia and nausea suggests a possible subarachnoid hemorrhage or aneurysm, requiring emergency evaluation. Other statements (A, B, C) are less specific.
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The nurse is repairing new prescriptions from the health care provider. Which prescription would require further clarification?
- A. Atorvastatin for hyperlipidemia in a client with angina pectoris
- B. Bupropion for smoking cessation in a client with emphysema
- C. Cyclobenzaprine for muscle spasms in a client with hepatitis
- D. Metronidazole for trichomoniasis in a client with Crohn disease
Correct Answer: C
Rationale: Cyclobenzaprine is contraindicated in hepatic impairment due to hepatitis, as it is metabolized by the liver, requiring clarification. Other prescriptions (A, B, D) are appropriate for the conditions.
The parent of a 7-month-old reports that the child has been crying and vomiting with a distended belly for the past 4 hours. The infant is now lying quietly in the parent's arms with a pulse of 200/min and respirations of 60/min. Which of the following components of SBAR (situation, background, assessment, recommendation/read back) communication is most important for the nurse to report?
- A. Client has been ill for approximately 4 hours
- B. Client has improved from apparent earlier distress
- C. Client is now lethargic with abnormal vital signs
- D. Does the health care provider want to order a laxative?
Correct Answer: C
Rationale: The infant's lethargy with tachycardia (200/min) and tachypnea (60/min) are critical, suggesting a serious condition like intussusception or volvulus, requiring urgent reporting. Duration , perceived improvement , and laxative suggestion are less critical.
The nurse understands that a priority goal of involuntary hospitalization of the severely mentally ill client is
- A. Re-orientation to reality
- B. Elimination of symptoms
- C. Protection from harm to self or others
- D. Return to independent functioning
Correct Answer: C
Rationale: Protection from harm to self or others. Involuntary hospitalization is required for individuals who are dangerous to themselves or others.
The nurse prepares equipment for insertion of a large bore nasogastric (NG) tube for a hospitalized client. Which actions should the nurse take to measure and mark the tube? Select all that apply.
- A. Fold tube in half and mark at the halfway point
- B. Extend tape measure from naris to stomach
- C. Measure from tip of nose to earlobe to xiphoid process
- D. Place a small piece of tape at the point of measurement
- E. Use rubber clamp after measuring to mark the point of measurement
Correct Answer: C,D
Rationale: To measure an NG tube, measure from nose to earlobe to xiphoid process for approximate insertion depth and mark with tape . Folding in half is inaccurate, measuring to stomach is vague, and rubber clamps are not standard.
An adult male has an IV in the left arm. The client calls the nurse and says that his left arm hurts. The LPN checks the IV site and notes that it is cool and blanched and not running well. What should the LPN do at this time?
- A. Flush the IV with normal saline
- B. Remove the IV immediately and start a new line
- C. Tell the charge nurse that the client's IV appears to be infiltrated
- D. Ask the charge nurse to check to see if the client has phlebitis
Correct Answer: B
Rationale: Cool, blanched skin and poor flow indicate infiltration; removing the IV and starting a new line prevents tissue damage.