Nokea
A client hospitalized with severe depression and suicidal ideation refuses to talk with the nurse. The nurse recognizes that the suicidal client has difficulty:
- A. Expressing feelings of low self-worth
- B. Discussing remorse and guilt for actions
- C. Displaying dependence on others
- D. Expressing anger toward others
Correct Answer: A
Rationale: Clients with severe depression and suicidal ideation often struggle to express feelings of low self-worth , which contributes to their emotional withdrawal. Discussing remorse or dependence may be present but is less central. Expressing anger is more typical in other conditions like bipolar disorder.
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The nurse is caring for a pregnant woman with pregnancy induced hypertension (PIH) receiving magnesium sulfate intravenously. In assessing the client, it is noted that respirations are 12, pulse and blood pressure have dropped significantly, and 8 hour output is 200 ml. What should the nurse do first?
- A. Administer calcium gluconate
- B. Call the provider immediately
- C. Discontinue the magnesium sulfate
- D. Perform additional assessments
Correct Answer: C
Rationale: The assessments strongly suggest magnesium sulfate toxicity. The nurse must discontinue the IV immediately and take measures to ensure the safety of the client.
The nurse is changing a dressing. Which event indicates a break in sterile technique?
- A. The nurse opens the sterile dressing set by opening the first flap away from herself.
- B. The nurse turns around when answering a question asked by the client in the other bed.
- C. The nurse opens the dressing set on the overbed table.
- D. The nurse pours sterile saline into the container in the dressing set.
Correct Answer: B
Rationale: Turning around risks contaminating the sterile field by passing non-sterile areas over it. Opening flaps away, using the table, or pouring saline maintain sterility.
The nurse is preparing to administer a scheduled vaccine to a pediatric client with hemophilia. Which of the following actions should the nurse take? Select all that apply.
- A. Administer ibuprofen for pain relief.
- B. Apply a warm compress to the injection site.
- C. Hold firm pressure to the injection site for 5 minutes.
- D. Massage the injection site to disperse the medication.
- E. Use the smallest bore and shortest needle length indicated.
Correct Answer: C,E
Rationale: Firm pressure for 5 minutes (C) and using a small, short needle (E) minimize bleeding in hemophilia. Ibuprofen (A) increases bleeding risk, warm compresses (B) may worsen bleeding, and massage (D) can cause hematoma.
A 4-year-old admitted with Wilms tumor is scheduled for a right nephrectomy in the morning. Which nursing action is a priority pre-operatively?
- A. Assessment of the child's emotional maturity level
- B. Auscultating for adventitious breath sounds
- C. Monitoring blood pressure closely
- D. Reinforcing instructions not to palpate the abdomen
Correct Answer: D
Rationale: Avoiding abdominal palpation (D) prevents tumor rupture in Wilms tumor, a critical pre-operative priority. Emotional assessment (A), lung sounds (B), and BP monitoring (C) are important but secondary.
A nurse is caring for an elderly client who had a colectomy for removal of cancer 2 days ago. The client is becoming increasingly restless and has been given IV morphine every 2 hours for severe pain. Respirations are 28/min and shallow. Which arterial blood gas results best indicate that the client is in acute respiratory failure and needs immediate intervention?
- A. PaO2 49 mm Hg (6.5 kPa), PaCO2 60 mm Hg (8.0 kPa)
- B. PaO2 64 mm Hg (8.5 kPa), PaCO2 45 mm Hg (6.0 kPa)
- C. PaO2 70 mm Hg (9.3 kPa), PaCO2 30 mm Hg (4.0 kPa)
- D. PaO2 86 mm Hg (11.5 kPa), PaCO2 25 mm Hg (3.33 kPa)
Correct Answer: A
Rationale: PaO2 < 50 mm Hg and PaCO2 > 50 mm Hg (A) indicate acute respiratory failure, requiring immediate intervention. Other options show less severe hypoxemia or normal values.