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A client has driven himself to the emergency department. He is 50 years old, has a history of hypertension, and informs the nurse that his father died from a heart attack at age 60. The client is presently complaining of indigestion. The nurse connects him to an electrocardiogram monitor and begins administering oxygen at 2 L/minute per nasal cannula. The nurse's next action would be to:
- A. Call for the physician.
- B. Start an I.V. line.
- C. Obtain a portable chest radiograph.
- D. Draw blood for laboratory studies.
Correct Answer: A
Rationale: Indigestion in a client with cardiac risk factors may indicate an MI. Calling the physician promptly ensures rapid evaluation and intervention, such as ECG or medications.
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The nurse is teaching a client who has been diagnosed with tuberculosis how to avoid spreading the disease to family members. Which statement(s) by the client indicate(s) that he has understood the nurse's instructions? Select all that apply.
- A. I will need to dispose of my old clothing when I return home.
- B. I should always cover my mouth and nose when sneezing.
- C. I'll be important that I isolate myself from family when possible.
- D. I should use paper tissues to cough in and dispose of them promptly.
- E. I can use regular plates and utensils whenever I eat.
Correct Answer: B,D,E
Rationale: Covering the mouth when sneezing (B), using tissues for coughing and disposing of them (D), and using regular utensils (E) prevent tuberculosis spread. Disposing of clothing is unnecessary. Isolation is only needed until the client is non-infectious (after 2–3 weeks of treatment).
The client with a cataract tells the nurse that she is afraid of being awake during eye surgery. Which of the following responses by the nurse would be the most appropriate?
- A. Have you ever had any reactions to local anesthetics in the past?
- B. What is it that disturbs you about the idea of being awake?
- C. With a local anesthetic, you won't have nausea and vomiting after the surgery.
- D. There's really nothing to fear about being awake. You'll be given a medication that will help you relax.
Correct Answer: B
Rationale: The nurse should give a client who seems fearful of surgery an opportunity to express her feelings. Only after identifying the client's concerns can the nurse address them appropriately. Asking about previous reactions to anesthetics or discussing nausea does not address the client's fear. Minimizing the client's feelings by saying there is nothing to fear ignores her concerns.
The primary healthcare provider (PHCP) prescribes medication via the buccal route. To correctly administer this medication, the nurse plans to place the medication
- A. in the client's ear while holding the pinna down and back.
- B. under the client's tongue.
- C. in the client's mouth toward the cheek.
- D. into the client's nasal passage.
Correct Answer: C
Rationale: Buccal administration involves placing the medication in the cheek pouch for absorption through the oral mucosa.
Which finding indicates effective hemodialysis?
- A. Decreased BUN.
- B. Increased potassium.
- C. Weight gain.
- D. Hypotension.
Correct Answer: A
Rationale: Decreased BUN indicates effective removal of waste products.
Which of the following represents the most appropriate nursing intervention for a client with pruritus caused by cancer or the treatment?
- A. Administration of antihistamines.
- B. Steroids.
- C. Silk sheets.
- D. Medicated cool baths.
Correct Answer: D
Rationale: Medicated cool baths soothe the skin and reduce pruritus, a common symptom in cancer patients, without the systemic effects of antihistamines or steroids.