Nokea
A client is on bed rest following an abdominal surgery. Which of the following findings indicates the need to increase the frequency of position changes?
- A. Flat rash on the client's ankle
- B. Non-blanching red area over the client's trochanter
- C. Ecchymosis on the client's left shoulder
- D. Petechiae on the client's right anterior thigh
Correct Answer: B
Rationale: The presence of a non-blanching red area over the client's trochanter is a concerning finding as it indicates possible pressure ulcer formation. This finding necessitates an increase in the frequency of position changes to prevent skin breakdown. Choices A, C, and D do not directly correlate with the need for increased position changes. A flat rash, ecchymosis, and petechiae may have different causes and would not be addressed by changing the client's position more frequently.
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A client who is unstable and requires frequent vital signs has an electronic blood pressure machine automatically measuring his blood pressure every 15 min. However, the machine is reading the client's blood pressure at more frequent intervals, and the readings are not similar. The nurse checks the machine settings and observes the additional readings, but the problem continues. Which of the following is the appropriate nursing action?
- A. Notify the manufacturer
- B. Disconnect the machine, and measure the blood pressure manually every 15 min
- C. Adjust the machine settings again
- D. Ignore the extra readings
Correct Answer: B
Rationale: The correct action in this scenario is to disconnect the electronic blood pressure machine and measure the client's blood pressure manually every 15 minutes. Given that the machine is malfunctioning and providing inconsistent readings, relying on manual measurements ensures accuracy and maintains the quality of care. Notifying the manufacturer (Choice A) may be necessary in the long run, but the immediate concern is the accuracy of the vital signs. Adjusting the machine settings again (Choice C) without resolving the underlying issue would not address the problem. Ignoring the extra readings (Choice D) could lead to incorrect assessment and compromise patient care. Therefore, the best course of action is to disconnect the machine and opt for manual blood pressure measurements until the issue is resolved.
A client enters the emergency department unconscious via ambulance from the client's workplace. What document should be given priority to guide the direction of care for this client?
- A. The statement of client rights and the client self-determination act
- B. Orders written by the healthcare provider
- C. A notarized original copy of advance directives brought in by the partner
- D. The clinical pathway protocol of the agency and the emergency department
Correct Answer: C
Rationale: In the scenario described, when a client arrives unconscious, priority should be given to a notarized original copy of advance directives brought in by the partner. Advance directives are legal documents that specify a person's healthcare wishes and decision-making preferences in advance. These directives guide healthcare providers in delivering care according to the client's preferences when the client is unable to communicate. The statement of client rights and the client self-determination act (Choice A) are important but do not provide specific care instructions. Orders written by the healthcare provider (Choice B) may not reflect the client's wishes. Clinical pathway protocols (Choice D) are valuable but do not address the individualized care preferences of the client.
During a health assessment, a client who takes herbal supplements makes a statement indicating an understanding of their use. Which statement is most indicative of this understanding?
- A. I use garlic for my menopausal symptoms.
- B. I use ginger when I get car sick.
- C. I take ginkgo biloba for headaches.
- D. I take echinacea to control cholesterol.
Correct Answer: C
Rationale: The correct answer is C because ginkgo biloba is commonly used to help with headaches, among other benefits. Choices A, B, and D are incorrect because garlic is not typically used for menopausal symptoms, ginger is mainly used for nausea and vomiting (not car sickness specifically), and echinacea is not known to control cholesterol.
The nurse is caring for a patient who has experienced a stroke causing total paralysis of the right side. To help maintain joint function and minimize the disability from contractures, passive range of motion (ROM) will be initiated. When should the nurse begin this therapy?
- A. After the acute phase of the disease has passed.
- B. As soon as the ability to move is lost.
- C. Once the patient enters the rehab unit.
- D. When the patient requests it.
Correct Answer: B
Rationale: Passive ROM exercises should begin as soon as the patient loses the ability to move the extremity or joint. Initiating passive ROM early helps prevent contractures and maintain joint function. Choice A is incorrect because delaying passive ROM until after the acute phase may lead to irreversible contractures. Choice C is not the best option as waiting until the patient enters the rehab unit delays crucial preventive measures. Choice D is incorrect as passive ROM should not be based on patient requests but on clinical indications and best practices.
A client in a provider's office tells the nurse that, 'I fast for several days each week to help control my weight.' The client takes several medications for various chronic issues. The nurse should explain to the client that which of the following mechanisms that result from fasting puts her at risk for medication toxicity?
- A. Increasing the metabolism of the medications over time
- B. Increasing the protein-binding response
- C. Increasing medications' transit time through the intestines
- D. Decreasing the excretion of medications
Correct Answer: B
Rationale: Fasting can lead to an increased protein-binding response of medications. This can result in a higher concentration of bound medications in the bloodstream, potentially causing toxicity as the medications may not be readily available for metabolism or excretion. Choice A is incorrect because fasting typically doesn't increase medication metabolism. Choice C is incorrect as fasting usually decreases transit time through the intestines. Choice D is incorrect since fasting generally does not decrease medication excretion.