Nokea
A client is admitted for COPD. Which findings would require the nurse's immediate attention?
- A. Nausea and vomiting
- B. Restlessness and confusion
- C. Low-grade fever and cough
- D. Irritating cough and liquefied sputum
Correct Answer: B
Rationale: Restlessness and confusion. Respiratory failure may be signaled by excessive somnolence, restlessness, aggressiveness, confusion, central cyanosis and shortness of breath. When these findings occur, arterial blood gases (ABGs) should be obtained.
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The nurse is caring for a man who had a transsphenoidal hypophysectomy earlier today. He says he has to spit a lot. What nursing action is essential?
- A. Ask him to blow his nose.
- B. Do a glucose test on his mouth secretions.
- C. Have him rinse his mouth with water.
- D. Ask him if he needs an antiemetic.
Correct Answer: B
Rationale: Excessive spitting may indicate cerebrospinal fluid (CSF) leak, which contains glucose; testing secretions confirms this serious complication.
A nursing assistant comes to the LPN/LVN and complains that she has more residents to care for than another nursing assistant (NA). She has one more resident assigned to her than the other NA. However, the other NA has more total care residents than the complaining NA. How should the LPN/LVN handle this situation?
- A. Tell the complaining NA that this is the assignment
- B. Promise to give her an easier assignment tomorrow
- C. Discuss with her the needs of her assignment and help her organize her care
- D. Tell her that the other NA will help her as needed
Correct Answer: C
Rationale: Discussing needs and organizing care addresses the NA's concerns constructively, promoting teamwork and efficiency without dismissing or deferring.
The nurse is monitoring a client who is going through barbiturate withdrawal. Which symptom is of most concern to the nurse?
- A. Nausea and vomiting
- B. Anxiety
- C. Hallucinations
- D. Seizures
Correct Answer: D
Rationale: Seizures in barbiturate withdrawal are life-threatening, requiring immediate intervention, unlike nausea, anxiety, or hallucinations.
A client on the psychiatric unit does not get to the dining room to eat because she is continually washing her hands and doesn't finish until after lunch. What should be included in the nursing care plan?
- A. Give the client a choice between eating lunch and performing her ritual.
- B. Tell the client an hour before lunch so she can perform her ritual before lunch.
- C. Discuss the problem with the client and ask her why she washes her hands so long.
- D. Tell the client she cannot wash her hands at all if she is going to be late for lunch.
Correct Answer: B
Rationale: Advance notice allows the client with OCD to complete rituals before lunch, facilitating nutrition without confrontation. Choices, discussions, or bans are less effective.
Laboratory Reference Ranges
Glucose (random)
71-200 mg/dL
(3.9-11.1 mmol/L)
The student nurse completes a clinical rotation in the emergency department. The instructor knows the student is able to prioritize care appropriately when the student visits which client first?
- A. 9 year-old crying with pain and swelling of the left ankle after a popping sound while playing soccer
- B. 29-year-old with neck swelling and increased pain 2 days after thyroidectomy
- C. 43-year-old with blood glucose of 423 mg/dL (23.5 mmol/L), dehydration, and trace ketones in urine
- D. 72-year-old who is incontinent with acute altered mental status and is yelling at staff
Correct Answer: B
Rationale: Neck swelling and pain post-thyroidectomy suggest possible hematoma or airway compromise, a life-threatening emergency requiring immediate assessment. Other conditions, while serious, are less immediately critical.