Nokea
A client who is scheduled for surgery today says to the nurse, 'Do you think I'll survive the surgery?' What is the best initial response for the nurse to give?
- A. Don't worry, your surgeon is good.'
- B. Tell me about your concerns.'
- C. I can call your clergyman.'
- D. We do a lot of these surgeries here; everything will be okay.'
Correct Answer: B
Rationale: Exploring concerns validates the client's fears, fostering trust and addressing anxiety therapeutically.
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Which of the following nursing assessment findings require immediate discontinuance of an antipsychotic medication?
- A. Involuntary rhythmic stereotypic movements and tongue protrusion
- B. Cheek puffing, involuntary movements of extremities and trunk
- C. Agitation, constant state of motion
- D. Hyperpyrexia, severe muscle rigidity, malignant hypertension
Correct Answer: D
Rationale: Hyperpyrexia, severe muscle rigidity, and malignant hypertension are signs of neuroleptic malignant syndrome (NMS), requiring immediate discontinuation of the antipsychotic.
The nurse is providing end-of-life care for a client. The client's spouse is crying and asks the nurse, 'Will you please stay with us?' Which of the following responses would be most appropriate for the nurse to make?
- A. I can come back at the end of my shift when I am able to stay longer.
- B. I will ask a friend or family member to stay with you if you would like.
- C. I can stay and sit with you for a short time if you would like.
- D. I will contact the chaplain to sit with you and your spouse
Correct Answer: C
Rationale: Offering to stay briefly provides immediate comfort while balancing duties. Delaying , delegating to others , or involving a chaplain may not address the spouse's immediate emotional needs.
As the nurse observes the student nurse during the administration of a narcotic analgesic IM injection, the nurse notes that the student begins to give the medication without first aspirating. What should the nurse do?
- A. Ask the student: 'What did you forget to do?'
- B. Stop. Tell me why aspiration is needed.
- C. Loudly state: 'You forgot to aspirate.'
- D. Walk up and whisper in the student's ear 'Stop. Aspirate. Then inject.'
Correct Answer: D
Rationale: This action is a direct threat to the client if the medication enters into the blood stream instead of the muscle. The purpose of aspiration with IM injections is to prevent the injection of the drug directly into the blood stream.
The client presents to the unit with complaints of shortness of breath. A tentative diagnosis of respiratory acidosis related to pneumonia is made. Which finding would support this diagnosis?
- A. $\mathrm{pH}$ of $7.45, \mathrm{CO}_2$ of $45, \mathrm{HCO}_3$ of 26
- B. $\mathrm{pH}$ of $7.35, \mathrm{CO}_2$ of $46, \mathrm{HCO}_3$ of 27
- C. $\mathrm{pH}$ of $7.34, \mathrm{CO}_2$ of $30, \mathrm{HCO}_3$ of 22
- D. $\mathrm{pH}$ of $7.44, \mathrm{CO}_2$ of $32, \mathrm{HCO}_3$ of 25
Correct Answer: B
Rationale: Respiratory acidosis is characterized by a low pH (<7.35) and elevated CO₂ (>45 mmHg) due to impaired gas exchange, as in pneumonia. Option B (pH 7.35, CO₂ 46, HCO₃ 27) is closest to this profile, with slight compensation. Options A, C, and D show normal or alkalotic pH or low CO₂.
A client is admitted with a lower urinary tract infection from an obstructing ureteral stone. Which tasks can the nurse delegate to the experienced unlicensed assistive personnel? Select all that apply.
- A. Collecting a urine specimen for culture and sensitivity
- B. Frequent turning and repositioning of the client
- C. Measuring and documenting urine output
- D. Monitoring the color and characteristics of urine output
- E. Teaching the client to strain urine while voiding
Correct Answer: B,C
Rationale: Turning and measuring output are within UAP scope. Collecting specimens , monitoring characteristics , and teaching require nursing judgment.