Nokea
A healthcare professional is assessing an adult client who has been immobile for the past 3 weeks. The healthcare professional should identify that which of the following findings requires further intervention?
- A. Erythema on pressure points
- B. Lower-extremity pulse strength of 2+
- C. Fluid intake of 3,000 mL per day
- D. A bowel movement every other day
Correct Answer: A
Rationale: Erythema on pressure points indicates potential skin breakdown due to prolonged immobility. It requires immediate intervention to prevent pressure ulcers. Lower-extremity pulse strength of 2+ is a normal finding, indicating adequate peripheral perfusion. Fluid intake of 3,000 mL per day is within the normal range and promotes hydration. A bowel movement every other day is a reasonable frequency for some individuals and does not necessarily indicate a need for immediate intervention in this scenario.
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A nurse in a provider's office is obtaining the health and medication history of a client who has a respiratory infection. The client tells the nurse that she is not aware of any allergies, but that she did develop a rash the last time she was taking an antibiotic. Which of the following information should the nurse give the client?
- A. "Rashes are very common, especially if you have dry skin. Did it go away on its own?"
- B. "Virtually all medications have adverse effects. It sounds like this could have been an adverse effect of the antibiotic."
- C. "It's unlikely that your doctor will prescribe an antibiotic for what seems to be a minor viral infection, so we shouldn't be concerned about that rash."
- D. "We need to document the exact medication you were taking because you might be allergic to it."
Correct Answer: D
Rationale: The correct answer is D. If a client reports developing a rash when taking a specific medication, even if they are not aware of any allergies, it is crucial to document this information. This is necessary to prevent future allergic reactions. Identifying the exact medication that caused the rash is essential as the client could have an allergy to it. Providing this information allows healthcare providers to avoid prescribing the same medication again, which could potentially lead to more severe allergic reactions or life-threatening situations. Choices A, B, and C are incorrect because they do not address the importance of documenting the specific medication that caused the adverse reaction or the potential risks of repeating the medication. Simply attributing the rash to common occurrences, adverse effects of medications in general, or assuming the rash is insignificant in the current context can overlook the critical aspect of identifying and avoiding allergens.
The nurse is caring for a client with cirrhosis of the liver. Which finding should the LPN/LVN report to the healthcare provider immediately?
- A. Yellowing of the skin and eyes
- B. Dark-colored urine
- C. Abdominal distention
- D. Confusion
Correct Answer: A
Rationale: Yellowing of the skin and eyes (jaundice) is a classic sign of liver dysfunction in clients with cirrhosis. Jaundice indicates the accumulation of bilirubin in the body due to impaired liver function. This finding suggests worsening liver damage and should be reported immediately to the healthcare provider for prompt evaluation and management. Dark-colored urine (choice B) is also a concerning symptom in liver disease, indicating possible bilirubin presence, but it is not as urgent as jaundice. Abdominal distention (choice C) and confusion (choice D) are common in cirrhosis but do not indicate an immediate need for healthcare provider notification compared to jajsondice.
The nurse is assessing a 17-year-old female client with bulimia. Which of the following laboratory reports would the nurse anticipate?
- A. Increased serum glucose
- B. Decreased albumin
- C. Decreased potassium
- D. Increased sodium retention
Correct Answer: C
Rationale: The correct answer is C, 'Decreased potassium.' Clients with bulimia often have decreased potassium levels due to frequent vomiting, which causes a loss of this essential electrolyte. This loss can lead to various complications such as cardiac arrhythmias. Option A, 'Increased serum glucose,' is not typically associated with bulimia. Option B, 'Decreased albumin,' is more related to malnutrition or liver disease rather than bulimia. Option D, 'Increased sodium retention,' is not a common finding in clients with bulimia; instead, they may experience electrolyte imbalances like hyponatremia due to purging behaviors.
An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be taken by the nurse is to:
- A. Check the carotid pulse
- B. Deliver 5 abdominal thrusts
- C. Give 2 rescue breaths
- D. Open the client's airway
Correct Answer: D
Rationale: In this scenario, the priority is to ensure the client has a clear airway to facilitate breathing. After verifying unresponsiveness and calling for help, the nurse should open the client's airway to aid in maintaining ventilation. Checking the carotid pulse (Choice A) may be important but comes after ensuring a clear airway. Delivering abdominal thrusts (Choice B) is indicated for choking, not for an unresponsive client. Giving rescue breaths (Choice C) is also important but only after the airway has been established.
A client is scheduled for hip surgery in an hour. Which of the following actions is the nurse's priority?
- A. Ensure that the client signs the consent form.
- B. Lock the client's valuables in a secure location.
- C. Verify the client's lab values in the medical record.
- D. Administer the prescribed preoperative sedative.
Correct Answer: A
Rationale: The nurse's priority is to ensure that the client signs the consent form before the hip surgery. This is crucial as it ensures that the client has provided informed consent for the procedure. Locking valuables, verifying lab values, and administering sedatives are important tasks but ensuring consent takes precedence as it directly impacts the client's right to make decisions about their care.