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A client has been on bed rest for several weeks. Which finding should the nurse identify as the priority during assessment?
- A. Musculoskeletal weakness
- B. Loss of appetite
- C. Increased heart rate during physical activity
- D. Left lower extremity tenderness
Correct Answer: D
Rationale: The nurse should prioritize assessing left lower extremity tenderness as it could indicate deep vein thrombosis, a serious condition that requires immediate attention. Musculoskeletal weakness, loss of appetite, and increased heart rate during physical activity are important but not as critical as a potential thrombotic event that could lead to life-threatening complications. Deep vein thrombosis is a common risk for individuals on prolonged bed rest due to reduced mobility and blood stasis.
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A nurse in a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which concept should the nurse and client discuss in the termination phase of the relationship?
- A. Loss
- B. Autonomy
- C. Confidentiality
- D. Accountability
Correct Answer: A
Rationale: In the termination phase of a nurse-client relationship, discussing 'loss' is crucial to help the client understand and process the end of the therapeutic relationship and any emotional impact. This discussion can aid in closure and transitioning out of the professional relationship. 'Autonomy' refers to the client's right to make decisions about their care, which is important throughout the relationship but not specifically in the termination phase. 'Confidentiality' is essential for maintaining trust but is not the primary focus during termination. 'Accountability' involves being answerable for one's actions, which is important in nursing practice but not a central topic in the termination phase of the relationship.
A healthcare professional is preparing to administer medications to a client. Which of the following client identifiers should the healthcare professional use to ensure medication safety?
- A. Ask the client to state their full name.
- B. Ask the client for their date of birth.
- C. Compare the client's wristband with the medication administration record.
- D. Ask the client for their room number.
Correct Answer: C
Rationale: Comparing the client's wristband with the medication administration record is a crucial step in ensuring medication safety. The wristband typically contains unique identifiers such as the client's name, date of birth, and medical record number, which should be cross-checked with the medication administration record to confirm the correct patient. Asking the client to state their name (Choice A) or date of birth (Choice B) may not be as reliable as the information can be misunderstood or miscommunicated. Asking for the room number (Choice D) is not a reliable client identifier for medication administration and does not confirm the patient's identity accurately.
The nurse is admitting a patient diagnosed with a stroke. The healthcare provider writes orders for 'ROM as needed.' What should the nurse do next?
- A. Restrict the patient's mobility as much as possible.
- B. Realize the patient is unable to move extremities.
- C. Move all the patient's extremities.
- D. Further assess the patient.
Correct Answer: D
Rationale: The correct answer is to further assess the patient. 'ROM as needed' stands for Range of Motion, indicating that the patient should have their limbs moved to maintain joint flexibility and muscle strength. Before initiating any movements, it is crucial to assess the patient's current condition to determine their abilities and limitations. Restricting mobility (choice A) is not appropriate as it contradicts the purpose of ROM exercises. Realizing the patient is unable to move extremities (choice B) assumes without assessment and can lead to inappropriate care. Moving all the patient's extremities (choice C) without assessing the patient first can be harmful, as it may cause pain or injury if done incorrectly. Therefore, further assessment is necessary to provide safe and effective care.
The LPN/LVN mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive?
- A. 31 gtt/min.
- B. 62 gtt/min.
- C. 93 gtt/min.
- D. 124 gtt/min.
Correct Answer: D
Rationale: To calculate the drops per minute for the client, first, convert the weight from pounds to kilograms by dividing 182 by 2.2, which equals 82.72 kg. Then, calculate the dose in mcg/min by multiplying the weight in kg by the rate (82.72 kg * 5 mcg/kg/min = 413.6 mcg/min). Next, convert 50 mg to mcg (50 mg * 1000 = 50,000 mcg). Divide the total mcg (50,000 mcg) by the dose per minute (413.6 mcg/min) to get approximately 121 gtt/min. However, since the drip factor is 60 gtt/ml, the correct answer is 124 gtt/min, ensuring the accurate administration rate of the medication. Therefore, choice 'D' is the correct answer. Choices 'A', 'B', and 'C' are incorrect as they do not accurately reflect the calculated drops per minute based on the given information.
The nurse is caring for a client diagnosed with hypothyroidism. Which finding should the nurse expect to observe?
- A. Weight gain
- B. Heat intolerance
- C. Increased appetite
- D. Frequent diarrhea
Correct Answer: A
Rationale: The correct answer is weight gain. In hypothyroidism, there is a decrease in metabolic rate, which can lead to weight gain. Heat intolerance (choice B) is more commonly associated with hyperthyroidism. Increased appetite (choice C) and frequent diarrhea (choice D) are not typical findings in hypothyroidism. Therefore, choices B, C, and D are incorrect.