Nokea
A client has massive bleeding from esophageal varices. In what order should the nurse and care team provide care for this client?
- A. Control hemorrhaging.
- B. Replace fluids.
- C. Relieve the client's anxiety.
- D. Maintain a patent airway.
Correct Answer: D, A, B, C
Rationale: The priority is to maintain a patent airway, control hemorrhaging, replace fluids, and then address anxiety to stabilize the client.
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A client with antisocial personality disorder tells the nurse, 'I punched the guy out because he deserved it and then the cops arrested me.' Which of the following responses would be most helpful to the client?
- A. It's wrong to punch others.'
- B. If you punch people out, you'll get into trouble.'
- C. I wouldn't do that again if I were you.'
- D. Don't ever do that again; you're an adult.'
Correct Answer: B
Rationale: Explaining consequences (legal trouble) helps the client understand the impact of their actions, aligning with therapeutic communication for antisocial personality disorder.
The nurse is caring for a client with a history of deep vein thrombosis who is prescribed enoxaparin (Lovenox). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild bruising.
- B. Bleeding gums.
- C. Headache.
- D. Nausea.
Correct Answer: B
Rationale: Bleeding gums indicate a potential bleeding complication with enoxaparin, requiring immediate reporting.
The nurse assists the physician in inserting a temporary pacemaker into the client. After the procedure, the nurse should verify that which of the following has been documented?
- A. The client's cardiovascular status.
- B. The client's emotional state.
- C. The type of sedation used.
- D. Pacemaker rate, type, and settings.
Correct Answer: D
Rationale: Documenting the pacemaker rate, type, and settings is critical to ensure proper function and patient safety post-procedure. While cardiovascular status and sedation are important, the pacemaker specifics are the priority for verification.
Sulfadiazine has been ordered for a client who has a urinary tract infection. Which of the following recommend is most appropriate for administering sulfonamides?
- A. Encourage the client to take the medication with meals.
- B. Instruct the client to drink at least 8 glasses of water a day.
- C. Measure the client's urine output.
- D. Instruct the client that the urine may turn reddish orange.
Correct Answer: B
Rationale: Adequate hydration (8 glasses of water daily) prevents crystalluria, a complication of sulfonamides.
Your client is experiencing general malaise. Which stage of infection is this client in?
- A. The incubation stage
- B. The illness stage
- C. The prodromal stage
- D. The convalescence stage
Correct Answer: B
Rationale: General malaise is characteristic of the illness stage, where symptoms of the infection are most prominent.