Nokea
A client who is intubated and has an intra-aortic balloon pump is restless and agitated. What action should the nurse perform first for comfort?
- A. Allow family members to remain at the bedside.
- B. Ask the family if the client would like a fan in the room.
- C. Keep the television tuned to the client's favorite channel.
- D. Speak loudly to the client in case of hearing problems.
Correct Answer: A
Rationale: The correct answer is A: Allow family members to remain at the bedside. This is the priority action as it provides emotional support and comfort to the client. Having familiar faces around can help calm the client and reduce agitation. It also promotes a sense of security and connection.
Choices B, C, and D are incorrect because they do not address the client's immediate need for comfort and emotional support. Asking about a fan, tuning the TV, or speaking loudly do not directly address the client's restlessness and agitation. Prioritizing the presence of family members is essential in this situation.
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The main action of luteinizing hormone is:
- A. Beginning of menses
- B. Menopause
- C. Ovulation
- D. Pregnancy
Correct Answer: C
Rationale: Luteinizing hormone triggers ovulation, releasing the mature egg from the ovary.
A client is 4 hours postoperative following abdominal surgery. The client's blood pressure has dropped from 120/80 mm Hg to 90/60 mm Hg. What action should the nurse take first?
- A. Administer an IV fluid bolus.
- B. Check the surgical site for bleeding.
- C. Place the client in a Trendelenburg position.
- D. Notify the healthcare provider.
Correct Answer: B
Rationale: The correct answer is B: Check the surgical site for bleeding. This is the first action the nurse should take as a sudden drop in blood pressure postoperatively could indicate internal bleeding, a common complication after abdominal surgery. By assessing the surgical site for bleeding, the nurse can identify and address the source of the hypotension promptly. Administering IV fluids (choice A) may be necessary but should come after determining the cause. Placing the client in Trendelenburg position (choice C) is not recommended as it can worsen venous return and increase intracranial pressure. Notifying the healthcare provider (choice D) should be done after the nurse has assessed the situation and taken immediate action.
Which action best demonstrates respect for autonomy when working with a client?
- A. Asks if the client has questions before signing a consent form
- B. Provides the client with accurate information when questioned
- C. Honors the promises made to the client and family
- D. Ensures fair treatment of the client compared to others
Correct Answer: A
Rationale: The correct answer is A because asking if the client has questions before signing a consent form shows respect for autonomy by allowing the client to make an informed decision. This action promotes the client's right to self-determination and involvement in the decision-making process. Choice B focuses on providing information when questioned but may not actively involve the client in the decision-making process. Choice C refers to honoring promises and not necessarily respecting autonomy. Choice D relates to fairness but does not directly address autonomy or the client's decision-making ability.
What statement by Mr. Ross indicates postural drainage has been effective?
- A. ‘I have been able to eat a little better during the past week.’
- B. ‘I have not gained any during the past week.’
- C. ‘I have not been able to sleep very well at night.’
- D. ‘I have been bringing up lots of sputum when I cough.’
Correct Answer: D
Rationale: Effective postural drainage clears secretions, evidenced by productive coughing.
A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active, and has no known risk factors for PE. What action by the nurse is most appropriate?
- A. Encourage the client to walk for 5 minutes each hour.
- B. Refer the client for smoking cessation classes.
- C. Teach the client about factor V Leiden testing.
- D. Explain to the client that sometimes no cause for the disease is found.
Correct Answer: C
Rationale: The correct answer is C because teaching the client about factor V Leiden testing is important in this scenario. Factor V Leiden is a genetic mutation that increases the risk of blood clot formation, including pulmonary embolism. Since the client has no known risk factors for PE, testing for this specific genetic mutation can help identify an underlying cause. Encouraging walking (choice A) is generally beneficial but may not address the root cause. Referring for smoking cessation (choice B) is not relevant in this case. Explaining that sometimes no cause is found (choice D) is not proactive and may lead to missed opportunities for prevention.