Nokea
A client is ready to be discharged from same-day surgery following an inguinal hernia repair. Which criteria must the client meet before the nurse can discharge the client?
- A. The client has transportation home via a taxicab.
- B. The client has pain no greater than 5 on a scale of 1 to 10.
- C. The client can walk to the bathroom by himself.
- D. The client states he will urinate later when he has more fluids.
Correct Answer: C
Rationale: The ability to walk to the bathroom indicates sufficient recovery of mobility and stability, a key discharge criterion. Pain control and urination are also important, but mobility is critical.
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The nurse is preparing to implement emergency care measures for the client who has just demonstrated signs and symptoms of a pulmonary embolism. Which primary health care provider prescription should the nurse implement first?
- A. Apply oxygen.
- B. Administer morphine sulfate.
- C. Start an intravenous (IV) line.
- D. Obtain an electrocardiogram (ECG).
Correct Answer: A
Rationale: The client needs oxygen immediately because of hypoxemia, which is most often accompanied by respiratory distress and cyanosis. The client should also have an IV line for the administration of emergency medications such as morphine sulfate. An ECG is useful in determining the presence of possible right ventricular hypertrophy. All of the interventions listed are appropriate, but the client needs the oxygen first.
The nurse is caring for a client with a history of breast cancer who is receiving tamoxifen (Nolvadex). The nurse should monitor the client for which of the following adverse effects?
- A. Endometrial cancer.
- B. Hypocalcemia.
- C. Alopecia.
- D. Weight loss.
Correct Answer: A
Rationale: Tamoxifen increases the risk of endometrial cancer, requiring monitoring for abnormal vaginal bleeding.
Your client is experiencing general malaise. Which stage of infection is this client in?
- A. The incubation stage
- B. The illness stage
- C. The prodromal stage
- D. The convalescence stage
Correct Answer: B
Rationale: General malaise is characteristic of the illness stage, where symptoms of the infection are most prominent.
The nurse walks into the room of a client who has a 'do not resuscitate' order and finds the client without a pulse, respirations, or blood pressure. What is the most appropriate action?
- A. Stay in the room and notify the nursing team for assistance.
- B. Push the emergency alarm to call a code.
- C. Dial the hospital phone number for a code.
- D. Pull the curtain and leave the room.
Correct Answer: D
Rationale: For a DNR client, no resuscitation is performed. The nurse should respectfully leave the room after ensuring privacy, notifying the team as needed for post-mortem care.
The nurse is assessing a client with a suspected urinary tract infection. Which of the following symptoms is most likely to be present?
- A. Flank pain.
- B. Hypotension.
- C. Bradycardia.
- D. Dry skin.
Correct Answer: A
Rationale: Flank pain is a common symptom of a urinary tract infection, especially if it involves the kidneys.