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A client complaining of severe shortness of breath is diagnosed with congestive heart failure. The nurse observes a falling pulse oximetry. The client's color changes to gray and she expectorates large amounts of pink frothy sputum. The first action of the nurse would be which of the following?
- A. Call the health care provider
- B. Check vital signs
- C. Position in high Fowler's
- D. Administer oxygen
Correct Answer: D
Rationale: Administer oxygen. In a medical emergency, airway and breathing are prioritized. Oxygen administration addresses the immediate respiratory distress.
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The nurse is providing postpartum teaching for a non-nursing mother. Which of the client's statements indicates the need for additional teaching?
- A. I'm wearing a support bra.
- B. I'm expressing milk from my breast.
- C. I'm drinking four glasses of fluid during a 24-hour period
- D. While I'm in the shower, I'll keep the water from running over my breasts
Correct Answer: B
Rationale: Non-nursing mothers should avoid expressing milk, as it stimulates further production. Support bras, adequate fluids, and avoiding breast stimulation are correct practices.
The nurse enters the room of a client with dementia and observes the client grimacing while pulling at the indwelling urinary catheter. The nurse notes blood trickling from the urinary meatus and pink-tinged urine in the urinary drainage bag. It would be a priority for the nurse to
- A. obtain a urine specimen for urinalysis
- B. deflate the balloon of the urinary catheter
- C. remove the urinary catheter in a single swift motion
- D. use sterile gauze to absorb the blood around the meatus
Correct Answer: B
Rationale: Blood and grimacing suggest trauma or irritation from the catheter. Deflating the balloon allows safe removal to prevent further injury, pending provider orders.
The nurse is caring for a client who experienced a sexual assault and has posttraumatic stress disorder. The client states, 'It is all my fault. I should not have accepted a drink from a stranger I met at a bar.' Which of the following responses would be most appropriate for the nurse to make?
- A. Those thoughts are not good for you. You should try to stop thinking about the assault.
- B. You have to stop blaming yourself for the assault so you can move on with your life.
- C. It may take time to overcome your thoughts and feelings related to the assault.
- D. You could not have anticipated the assault. You did not deserve or ask for it.
Correct Answer: D
Rationale: This response validates the client's feelings while gently correcting self-blame, reinforcing that the assault was not their fault and promoting a supportive therapeutic environment.
The nurse is caring for a client after a motor vehicle accident. The client's injuries include 2 fractured ribs and a concussion. The nurse notes which findings as expected neurological changes for the client with a concussion? Select all that apply.
- A. Amnesia
- B. Asymmetrical pupillary constriction
- C. Brief loss of consciousness
- D. Headache
- E. Loss of vision
Correct Answer: A,C,D
Rationale: Amnesia (A), brief loss of consciousness (C), and headache (D) are common symptoms of concussion due to temporary brain dysfunction.
The nurse on the telemetry unit is preparing client medications in the medication room. Which of the following actions should the nurse perform to be consistent with client safety practices related to medication administration? Select all that apply.
- A. Confirm the client's identity, medication, dosage, time, and route prior to medication administration
- B. Do not administer any medication that is damaged or has an unreadable label
- C. Place all medications in a dispensing cup before taking them to a client's room
- D. Review laboratory values before administering anticoagulants
- E. Wear gloves when handling transdermal medication patches
Correct Answer: A,B,D,E
Rationale: These actions align with safe medication administration practices: verifying the 'five rights' (A), ensuring medication integrity (B), checking relevant lab values for anticoagulants (D), and using gloves to prevent absorption of transdermal medications (E).