Nokea
A client is receiving an infusion of alteplase (Activase) for an intra-arterial clot. The client begins to mumble and is disoriented. What action by the nurse takes priority?
- A. Assess the client's neurological status
- B. Notify the Rapid Response Team
- C. Prepare to administer vitamin K
- D. Turn down the infusion rate
Correct Answer: B
Rationale: Clients on fibrinolytic therapy are at high risk of bleeding. Sudden neurologic signs may indicate a hemorrhagic stroke. The nurse should first call the Rapid Response Team based on the client's manifestations, then perform a thorough neurological examination.
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A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audience should the nurse provide this service?
- A. African-American churches
- B. Asian-American groceries
- C. High school sports camps
- D. Women's health clinics
Correct Answer: A
Rationale: Providing services at African-American churches has the potential to reach this priority population, as African-Americans are at higher risk for hypertension. While hypertension education is important for all groups, this is the priority population for this intervention.
A student nurse is assessing the peripheral vascular system of an older adult. What action by the student would assess the locally primary interview?
- A. Assessing blood pressure in both upper extremities
- B. Auscultating the carotid arteries for any bruits
- C. Classifying capillary refill of 4 seconds as normal
- D. Palpating both carotid arteries at the same time
Correct Answer: D
Rationale: The student should not compress both carotid arteries at the same time to avoid brain ischemia. Blood pressure should be taken and compared in both arms. Prolonged capillary refill is considered to be greater than 5 seconds in an older adult, so classifying refill of 4 seconds as normal would not require intervention. Bruits should be auscultated.
A client is postoperative after surgery to repair a fractured hip and has a history of atrial fibrillation. What action by the nurse is most important to prevent wound infections?
- A. Performing hand hygiene before client contact
- B. Changing the surgical dressing daily
- C. Monitoring the client's daily white blood cell count
- D. Administering prophylactic antibiotics
Correct Answer: A
Rationale: Hand hygiene is the best way to prevent infections in hospitalized clients. Dressing changes should be done with sterile technique, but hand hygiene is the most critical step. Assessing vital signs and white blood cell count will not prevent infection.
A client has been bedridden for several days after major abdominal surgery. What action does the nurse delegate to the unlicensed assistive personnel (UAP) for deep vein thrombosis (DVT) prevention? (Select all that apply.)
- A. Apply compression stockings
- B. Assist with ambulation
- C. Assist with deep breathing
- D. Offer fluids frequently
- E. Teach leg exercises
Correct Answer: A,B,D
Rationale: The UAP can apply compression stockings, assist with ambulation, and offer fluids to prevent DVT. Deep breathing does not reduce DVT risk, and teaching is a nursing function.
A nurse is assessing a client with peripheral artery disease (PAD). The client states walking five blocks is possible without pain. What question asked next by the nurse will give the best information?
- A. Could you walk further than that a few months ago?
- B. Do you walk mostly uphill, downhill, or on flat surfaces?
- C. Have you ever considered swimming instead of walking?
- D. How much pain medication do you take each day?
Correct Answer: A
Rationale: As PAD progresses, it takes less oxygen demand to cause pain. Needing to cut down on activity to be pain-free indicates the client's disease is worsening. The other questions are useful but not as critical.