Nokea
A home care nurse is planning activities for the day. Which of the following clients should the nurse see FIRST?
- A. A new mother is breastfeeding her two-day-old infant who was born five days early.
- B. A man discharged yesterday following treatment with IV heparin for a deep vein thrombosis.
- C. An elderly woman discharged from the hospital three days ago with pneumonia.
- D. An elderly man who used all his diuretic medication and is expectorating pink-tinged mucus.
Correct Answer: D
Rationale: symptoms of pulmonary edema; requires immediate attention
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A 26-year-old woman has missed her menstrual period. The client's last menstrual period began May 8 and ended May 12.
The nurse determines that her EDC (estimated date of confinement) is
- A. February 1.
- B. February 15.
- C. February 19.
- D. March 14.
Correct Answer: B
Rationale: Strategy: Remember Naegele's rule. (1) should add seven days (2) correct-when using the Naegele rule, add seven days to first day of last menstrual period and subtract three months (3) incorrectly started with the last day of the menstrual cycle (4) incorrect
The nurse is teaching a client with a new diagnosis of ulcerative colitis about mesalamine (Asacol). Which of the following instructions should the nurse include?
- A. Take the medication with grapefruit juice
- B. Report any fever or sore throat
- C. Stop the medication if symptoms improve
- D. Avoid taking with meals
Correct Answer: B
Rationale: Fever or sore throat may indicate bone marrow suppression, a serious mesalamine side effect. Options A, C, and D are incorrect: grapefruit juice is irrelevant, stopping the medication risks relapse, and it can be taken with meals.
A client returns from surgery after an open reduction of a femur fracture. There is a small bloodstain on the cast. Four hours later, the nurse observes that the stain has doubled in size. What is the best action for the nurse to take?
- A. Call the health care provider
- B. Access the use of a window in the cast
- C. Simply record the findings in the nurse's notes only
- D. Outline the spot with a pencil and note the time and date on the cast
Correct Answer: D
Rationale: Outline the spot with a pencil and note the time and date on the cast. This is a good way to assess the amount of bleeding over a period of time. The bleeding does not appear to be excessive and some bleeding is expected with this type of surgery. The bleeding should also be documented in the nurse's notes.
The nurse is caring for a client with a history of cirrhosis who is receiving lactulose (Chronulac) 30 mL PO tid. Which of the following findings would be of GREATest concern to the nurse?
- A. Ammonia level of 40 mcg/dL.
- B. Potassium of 3.5 mEq/L.
- C. Diarrhea with 4 stools per day.
- D. Sodium of 140 mEq/L.
Correct Answer: C
Rationale: Diarrhea with 4 stools per day suggests lactulose overdose, risking dehydration and electrolyte imbalance in cirrhosis. Options A, B, and D are normal or expected: ammonia 40 mcg/dL is controlled, potassium 3.5 mEq/L is normal, and sodium 140 mEq/L is normal.
Which of the following nursing interventions is MOST important when caring for a client who has just been placed in physical restraints?
- A. Prepare PRN dose of psychotropic medication.
- B. Check that the restraints have been applied correctly.
- C. Review hospital policy regarding duration of restraints.
- D. Monitor the client's needs for hydration and nutrition while restrained.
Correct Answer: B
Rationale: assessment; while a client is restrained, physiological integrity is important; monitoring positioning, tightness, and peripheral circulation is essential; nurse documents the client's response and clinical status after being restrained