Nokea
A client is in the emergency room in critical condition and hypotensive. Her
spouse is distraught. What is the priority nursing action?
- A. Maintain the client's blood pressure
- B. Call a chaplain
- C. Provide the spouse a chair
- D. Ask the client's spouse to explain what happened
Correct Answer: A
Rationale:
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What is a classic symptom assessed in clients with lupus?
- A. Butterfly rash
- B. Chvostek's sign
- C. Ovid's sign
- D. Heberden's nodes
Correct Answer: A
Rationale:
The nurse is planning care for a post-operative client after a total hip
arthroplasty. What is the priority nursing intervention?
- A. Observe client for changes in mental status
- B. Use aseptic technique for wound care and emptying of drains
- C. Keep the client's heels off the bed
- D. Perform neurovascular assessments per protocol
Correct Answer: D
Rationale:
Which of the following statements made by a client diagnosed with human
immunodefiency virus (HIV) would require further teaching?
- A. "I will have to be careful and avoid crowds."?
- B. "I will take prescribed medications."?
- C. "I will have to take medications for the rest of my life."?
- D. "I will only need to take HIV medications for 6 months, and I will be cured
Correct Answer: D
Rationale:
A client is immobile and requires mechanical ventilation with a tracheostomy.
She has a pressure injury on her coccyx measuring 5 cm by 3 cm. the nurse
observes bone and tendon at the base of the wound. How would the nurse
document this wound?
- A. Stage III pressure injury
- B. A stage II pressure injury
- C. A non-staging pressure injury
- D. Stage IV pressure injury
Correct Answer: D
Rationale:
A client is diagnosed with systemic sclerosis (scleroderma). What symptoms is
the first to occur?
- A. Tachycardia
- B. Raynaud's phenomenon
- C. Intense wrinkle
- D. Joint pain
Correct Answer: B
Rationale: