Nokea
A client has a bovine graft inserted into the left arm for hemodialysis. During the immediate postoperative period, which of the following actions, if performed by the nurse, is BEST?
- A. Restart the IV above the level of the graft.
- B. Take blood pressures only on the right arm.
- C. Elevate the left arm above the level of the heart.
- D. Check the radial pulse on the left arm q 4h.
Correct Answer: B
Rationale: BP should always be taken on the opposite arm from the graft
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An elderly man diagnosed with chronic schizophrenia is being followed in a partial hospitalization program. The client has been on long-term antipsychotic medication and has recently developed symptoms of tardive dyskinesia.
The nurse's documentation on this client should include
- A. assessment of ADL (self-care) ability.
- B. Mini-Mental Status Examination (MMSE).
- C. Abnormal Involuntary Movement Scale (AIMS).
- D. Modified Overt Aggression Scale (MOAS).
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) assessment of client's abilities to complete his activities of daily living (ADLs) needs to be completed and revised with a client who is aging and chronically mentally ill (2) measures cognitive function (3) correct-is most widely accepted examination to Test for the presence of tardive dyskinesia (4) assessment tool for determining severity of aggression; usually utilized to determine nature, severity, and prevalence of aggression in an inpatient population
A client received six units of regular insulin three hours ago.
- A. Which observation would be most concerning for a client who received six units of regular insulin three hours ago?
- B. Kussmaul respirations and diaphoresis.
- C. Anorexia and lethargy.
- D. Diaphoresis and trembling.
- E. Headache and polyuria.
Correct Answer: C
Rationale: Regular insulin peaks in 2-4 hours, and diaphoresis and trembling are classic signs of hypoglycemia, a potentially life-threatening complication requiring immediate intervention (e.g., administering skim milk). Kussmaul respirations indicate hyperglycemia, while anorexia, lethargy, headache, and polyuria are not specific to hypoglycemia.
The nurse is assessing a client with suspected appendicitis. Which of the following findings would the nurse expect to observe?
- A. Pain relieved by pressure at McBurney's point.
- B. Rebound tenderness at McBurney's point.
- C. Pain in the left lower quadrant.
- D. Decreased bowel sounds in all quadrants.
Correct Answer: B
Rationale: rebound tenderness at McBurney's point is a classic sign of appendicitis
A client with a statement indicating the use of a defense mechanism.
Which of the following statements, if made by a client to the nurse, would indicate that the client is using the defense mechanism of conversion?
- A. I love my family with all my heart even though they don't love me.'
- B. I was unable to take my final exams because I was unable to write.'
- C. I don't believe I have diabetes. I feel perfectly fine.'
- D. If my wife was a better housekeeper I wouldn't have such a problem.'
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) indicates reaction formation (2) correct-client has converted his anxiety over school performance into a physical symptom that interferes with his ability to perform (3) indicates denial (4) indicates projection
The nurse is caring for a two-month-old infant. A pH probe test indicates that the infant has reflux. Which nursing action is MOST appropriate?
- A. Hold the next feeding.
- B. Teach the mother CPR.
- C. Maintain a normal feeding schedule.
- D. Elevate the head of the bed.
Correct Answer: D
Rationale: infant with reflux should be maintained in an upright position; head of the bed should be raised at a 30° angle