Nokea
A client with lung cancer is admitted to palliative care. What is the nurse's priority assessment?
- A. Monitor respiratory status and oxygenation.
- B. Evaluate the client's mental status and cognition.
- C. Check the client's pain level and provide comfort.
- D. Assess the client's nutritional status and appetite.
Correct Answer: A
Rationale: Correct Answer: Monitoring respiratory status and oxygenation is crucial in clients with lung cancer, as metastasis to the lungs or pleural effusion can compromise breathing. This assessment helps in early identification of respiratory distress and the need for interventions to maintain adequate oxygenation. Choice B is important but not the priority in this situation. Evaluating mental status and cognition should follow after ensuring the client's physiological needs are met. Choice C, checking pain level and providing comfort, is essential but secondary to assessing respiratory status. Choice D, assessing nutritional status and appetite, is also important but not the priority when the client's breathing is at risk.
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Which medication should the nurse withhold if the client's serum potassium level is 6.2 mEq/L?
- A. Losartan
- B. Spironolactone
- C. Metoprolol
- D. Furosemide
Correct Answer: B
Rationale: The correct answer is B: Spironolactone. Spironolactone is a potassium-sparing diuretic that can lead to hyperkalemia. With potassium levels already elevated at 6.2 mEq/L, withholding Spironolactone is essential to prevent further increase in potassium levels, which could result in dangerous cardiac arrhythmias. Losartan (Choice A) is an angiotensin receptor blocker and does not directly affect potassium levels. Metoprolol (Choice C) is a beta-blocker and also does not impact potassium levels significantly. Furosemide (Choice D) is a loop diuretic that can actually lower potassium levels, so it would not be the medication to withhold in this case.
What information should the nurse include in the client's health record after a fall in the bathroom?
- A. Client fell while trying to go to the bathroom
- B. The UAP left the client alone and a fall occurred
- C. The client was found on the floor with no pulse
- D. The client fell, sustaining a fracture to the left hip
Correct Answer: D
Rationale: The correct answer is D because the nurse should document factual, objective information such as the injury sustained by the client. Reporting the specific injury, like a fracture to the left hip, is crucial for accurate medical records. Choices A, B, and C lack specific detail about the injury and focus on different aspects of the fall that are not as pertinent for the health record. Choice A only mentions the fall without specifying the injury, choice B introduces blame without focusing on the client's condition, and choice C adds unnecessary information about the client's pulse which is not directly related to the fall injury.
While assessing several clients in a long-term health care facility, which client is at the highest risk for developing decubitus ulcers?
- A. A 79-year-old malnourished client on bed rest
- B. An obese client who uses a wheelchair
- C. A client who had 3 episodes of incontinent diarrhea
- D. An 80-year-old ambulatory diabetic client
Correct Answer: A
Rationale: The correct answer is A: A 79-year-old malnourished client on bed rest. This client is at the highest risk for developing decubitus ulcers due to being malnourished and on bed rest, leading to decreased mobility and poor nutrition. This combination puts the client at significant risk for skin breakdown and pressure ulcers. Choice B is incorrect because although obesity is a risk factor for developing pressure ulcers, immobility and poor nutrition are higher risk factors. Choice C is incorrect as incontinence can contribute to skin breakdown but is not as high a risk factor as immobility and poor nutrition. Choice D is incorrect as an ambulatory client, even if diabetic, has better mobility than a bedridden client and is at lower risk for developing decubitus ulcers.
A 66-year-old woman is retiring and needs health insurance. To which agency should the employee health nurse refer her?
- A. Medicaid
- B. Medicare
- C. COBRA
- D. Private insurance
Correct Answer: B
Rationale: The correct answer is B: Medicare. Medicare is the federal health insurance program for individuals aged 65 and older, so it is the most suitable option for the 66-year-old woman retiring. Medicaid (choice A) is a state and federally funded program for low-income individuals and families, not specifically for retirees. COBRA (choice C) allows employees to continue their employer-sponsored health insurance for a limited time after leaving employment. Private insurance (choice D) refers to health insurance plans purchased directly from private insurance companies.
The nurse is preparing a female client for discharge after being treated for a urinary tract infection (UTI). Which statement by the client indicates a need for further teaching?
- A. I will use douches regularly to prevent future infections.
- B. I should drink at least 8 glasses of water a day.
- C. I should avoid tight-fitting clothing.
- D. I will wipe from front to back after using the toilet.
Correct Answer: A
Rationale: The correct answer is A. Using douches is not recommended as it can disrupt the natural flora and increase the risk of infections. Choices B, C, and D are all correct statements that can help prevent UTIs. Drinking an adequate amount of water helps flush out bacteria, avoiding tight-fitting clothing promotes ventilation and reduces moisture, and wiping from front to back prevents the spread of bacteria from the anal region to the urethra.