Nokea
A client is being admitted with a spinal cord transection at C7. Which of the following assessments take priority upon the client's arrival?
- A. Reflexes.
- B. Bladder function.
- C. Blood pressure.
- D. Temperature.
- E. Respirations.
Correct Answer: C,E
Rationale: Respirations and blood pressure are the priority assessments for a C7 spinal cord injury, as this level can impair diaphragmatic function and cause neurogenic shock, both life-threatening. Reflexes, bladder function, and temperature are important but secondary to airway and circulation stability.
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A client with renal calculi has hematuria. The nurse should:
- A. Monitor urine output.
- B. Notify the physician immediately.
- C. Restrict fluids.
- D. Apply ice to the flank.
Correct Answer: A
Rationale: Hematuria is expected with renal calculi; monitoring ensures no excessive bleeding.
Post-cystectomy, a client asks about the purpose of the ileal conduit. The nurse explains it is to:
- A. Store urine in the bladder.
- B. Divert urine to an external pouch.
- C. Filter blood in the kidneys.
- D. Reabsorb water in the intestines.
Correct Answer: B
Rationale: An ileal conduit diverts urine from the ureters to a stoma, collected in an external pouch.
The right hand of a client with multiple sclerosis trembles severely whenever she attempts a purposeful act, such as picking up her coffee cup or buttoning her dress. Which is the best legal documentation in nurses' notes of the chart for this client assessment?
- A. "Has an intention tremor of the right hand."
- B. "Right-hand tremor worsens with purposeful acts."
- C. "Needs assistance with dressing and eating due to severe trembling and clumsiness."
- D. "Slight shaking of right hand increases to severe tremor when client tries to button her clothes or drink from a cup."
Correct Answer: D
Rationale: The most detailed and accurate documentation is: "Slight shaking of right hand increases to severe tremor when client tries to button her clothes or drink from a cup," as it describes the intention tremor specifically and legally.
A client with jaundice has pruritis and states that he has areas of irritation from scratching. What measures can the nurse discuss to prevent skin breakdown? Select all that apply.
- A. Avoid lotions containing calamine.
- B. Take baking soda baths.
- C. Keep nails short and clean.
- D. Rub with knuckles instead of nails.
- E. Massage skin with alcohol.
- F. Increase sodium intake in diet.
Correct Answer: B,C,D
Rationale: Baking soda baths (B), short nails (C), and rubbing with knuckles (D) reduce itching and prevent skin breakdown. Calamine (A) is helpful, not avoided. Alcohol (E) dries skin, worsening irritation. Sodium (F) is unrelated.
The nurse is preparing to transfuse fresh frozen plasma (FFP) to a client. Which of the following actions would be appropriate for the nurse to take?
- A. Obtain baseline platelet count
- B. Verify ABO compatibility
- C. Infuse over two to four hours
- D. Obtain a 12-lead electrocardiogram
Correct Answer: B
Rationale: FFP requires ABO compatibility verification to prevent transfusion reactions, as it contains plasma proteins and antibodies. Platelet counts are irrelevant to FFP, infusion time is typically 30–60 minutes, and an ECG is not routinely required.