Nokea
A client is admitted to the hospital with a diagnosis of deep vein thrombosis. During the initial assessment, the client complains of sudden shortness of breath. The SaO2 is 87. The priority nursing assessment at this time is
- A. bowel sounds
- B. heart rate
- C. peripheral pulses
- D. lung sounds
Correct Answer: D
Rationale: Lung sounds are critical assessments at this point. The nurse should be alert to crackles or a pleural friction rub, highly suggestive of a pulmonary embolism.
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The nurse is caring for a client with partial hearing loss. Which of the following actions will promote effective communication? Select all that apply.
- A. Dim lights to prevent overstimulation
- B. Directly face the client when speaking
- C. Ensure hearing aids are properly applied
- D. Provide written information to supplement conversation
- E. Raise voice to speak loudly to the client
Correct Answer: B,C,D
Rationale: Facing the client aids lip-reading, properly applied hearing aids optimize hearing, and written information reinforces verbal communication. Dimming lights may hinder lip-reading, and shouting distorts speech.
Laboratory reference ranges
Platelets
150,000-400,000/mm3
(150-400 x 10%/L)
The nurse prepares to administer morning medications to assigned clients. Which prescription should the nurse clarify with the health care provider?
- A. Clopidogrel for client with history of stroke and platelet count of 154,000/mm² (154 x 10â¹/L)
- B. Losartan for client with hypertension who is 8 weeks pregnant
- C. Prednisone for client with herpes simplex lesions and Bell palsy
- D. Tiotropium for client with pneumonia and chronic obstructive pulmonary disease
Correct Answer: B
Rationale: Losartan is contraindicated in pregnancy due to fetal harm risks. Clopidogrel is safe with normal platelet counts, prednisone is appropriate for Bell palsy, and tiotropium is suitable for COPD despite pneumonia.
The licensed practical nurse is monitoring a client receiving an IV of Nipride in D5W. The IV bag has a foil covering, and the nurse notes that the IV fluid has a light brownish tint. The nurse should:
- A. Discard the solution.
- B. Obtain a bag of normal saline.
- C. Cover both the solution bag and the IV tubing with foil.
- D. Do nothing because the solution is expected to be light brown in color.
Correct Answer: D
Rationale: Nipride (nitroprusside) is light-sensitive and turns light brown, which is normal if protected by foil. No action is needed.
Which statements made by the client demonstrate a correct understanding of the home care of an ascending colostomy? Select all that apply.
- A. I will clarify with my health care provider before taking enteric-coated medications.
- B. I will irrigate the colostomy to promote regular bowel movements.
- C. I will limit eating foods such as broccoli and cauliflower to reduce odor.
- D. I will restrict my fluid intake to 2,000 milliliters of fluid a day.
- E. I will wait for the pouch to become completely full before emptying the contents.
Correct Answer: A,C
Rationale: Enteric-coated medications may not dissolve properly in an ascending colostomy due to shorter intestinal transit time, requiring provider consultation. Limiting odor-causing foods like broccoli helps manage odor. Irrigation is typically for descending/sigmoid colostomies, not ascending. Fluid intake should be adequate (not restricted), and pouches should be emptied when one-third to half full to prevent leaks.
The nurse is collecting data from a client who had a cesarean birth 12 hours ago. The client is restless, has a heart rate of 115/min, and is reporting dyspnea and anxiety. It would be a priority for the nurse to
- A. obtain a pulse oximetry reading for the client
- B. offer the client medication prescribed PRN for pain
- C. check the client's lower extremities for warmth and redness
- D. encourage guided imagery and breathing techniques for relaxation
Correct Answer: A
Rationale: Restlessness, tachycardia, dyspnea, and anxiety post-cesarean suggest pulmonary embolism, a common postpartum complication. Pulse oximetry assesses oxygenation urgently. Pain, DVT, or anxiety are less immediate concerns.