Nokea
A client is diagnosed with primary hypertension. Which assessment finding is most commonly associated with this diagnosis?
- A. Headache
- B. Dizziness
- C. Fatigue
- D. Edema
Correct Answer: A
Rationale: Headache (A) is the most commonly associated symptom with primary hypertension due to increased pressure in the blood vessels, leading to headaches. While dizziness (B), fatigue (C), and edema (D) may also occur in hypertension, headache is the most frequently reported symptom among individuals with primary hypertension.
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An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and is now requesting to go to the bathroom. Which action should the nurse implement?
- A. Assist the client to walk to the bathroom and do not leave the client alone.
- B. Request that the UAP assist the client onto a bedpan.
- C. Ask if the client needs to have a bowel movement or void.
- D. Assess the client's bladder to determine if the client needs to urinate.
Correct Answer: A
Rationale: Barbiturates cause central nervous system (CNS) depression, increasing the risk of falls. It is crucial for the nurse to assist the client to the bathroom to prevent potential injuries. Leaving the client alone may lead to accidents due to the effects of the medication. Monitoring and supporting the client during this activity is essential for ensuring safety and preventing falls.
A client with a history of diabetes mellitus is admitted with a blood glucose level of 600 mg/dL. What type of insulin should the nurse prepare to administer to this client?
- A. Regular insulin
- B. NPH insulin
- C. Lispro insulin
- D. Glargine insulin
Correct Answer: A
Rationale: In a client with a blood glucose level of 600 mg/dL, which indicates severe hyperglycemia or diabetic ketoacidosis, the nurse should prepare to administer regular insulin (A). Regular insulin has a rapid onset of action and is the preferred choice for immediate correction of high blood glucose levels. NPH insulin (B), lispro insulin (C), and glargine insulin (D) are not suitable for the rapid correction of severe hyperglycemia.
An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care?
- A. Do not massage any reddened areas.
- B. Encourage passive range of motion exercises on extremities.
- C. Position the client laterally, supine, and prone in sequence.
- D. Gently lift the client when moving into a desired position.
Correct Answer: D
Rationale: The essential nursing measure for a client with a fractured left hip on strict bedrest is to gently lift the client when moving into a desired position (D). This helps to avoid shearing forces and prevents further injury. Massaging reddened areas (A) should be avoided to prevent skin damage. Active range of motion exercises (B) may be limited due to pain and muscle spasms in the affected leg. The position described in (C) is contraindicated for a client with a fractured left hip as it may cause additional harm.
The nurse is preparing a client for surgery. What action is most important for the nurse to take?
- A. Ensure that the client signs the consent form.
- B. Review the client's allergies with the surgical team.
- C. Confirm the client's identity using two identifiers.
- D. Verify that the surgical site is marked.
Correct Answer: A
Rationale: Ensuring that the client signs the consent form (A) is the most crucial action before surgery. The consent form is legally and ethically necessary for the procedure to proceed. While reviewing allergies (B), confirming identity (C), and verifying the surgical site (D) are essential steps, obtaining the client's informed consent takes precedence to protect the client's rights and ensure a safe surgical experience.
The charge nurse observes that a demographic screen has been left open on a hallway computer by a nurse who is responding to a call light while the unlicensed assistive personnel (UAP) is involved in a personal phone call. Which action should the charge nurse take first?
- A. Page the unit manager to address the situation.
- B. Close the demographic screen on the computer.
- C. Instruct the UAP to end the phone call immediately.
- D. Send a UAP into the client's room to relieve the nurse.
Correct Answer: B
Rationale: The charge nurse's first action should be to close the demographic screen on the computer to protect patient confidentiality and prevent unauthorized access to sensitive information. This immediate response addresses the breach of patient privacy and ensures that patient data is secure, setting the right priority in managing the situation.