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A home health nurse is caring for an older adult client who just returned home following a total knee arthroplasty. Which of the following actions should the nurse take first?
- A. Assess mobility
- B. Monitor vital signs
- C. Provide pain relief
- D. Reinforce discharge teaching
Correct Answer: A
Rationale: Assessing mobility should be the nurse's priority as it ensures the client's safety and helps in developing an appropriate care plan. By evaluating the client's ability to move after the knee arthroplasty, the nurse can identify any immediate issues or complications that need to be addressed promptly. Monitoring vital signs, providing pain relief, and reinforcing discharge teaching are important aspects of care but assessing mobility takes precedence in ensuring the client's immediate well-being and identifying any potential risks.
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A nurse is assisting with monitoring a client who is at 40 weeks of gestation and is in active labor. The nurse recognizes late decelerations on the fetal monitor tracing. Which of the following actions should the nurse take?
- A. Apply oxygen at 10 L/min via face mask
- B. Position the client on their side
- C. Call for a Cesarean delivery
- D. Administer oxytocin
Correct Answer: B
Rationale: Late decelerations indicate uteroplacental insufficiency, and the priority nursing action is to improve placental perfusion. Positioning the client on their side, particularly the left side, can enhance blood flow to the placenta and fetus by reducing pressure on the vena cava and increasing cardiac output. Applying oxygen, although helpful, is not the initial priority in this situation. Calling for a Cesarean delivery is not warranted unless other interventions fail to correct the late decelerations. Administering oxytocin can worsen the condition by increasing uterine contractions, exacerbating fetal distress.
A healthcare professional is collecting data from a client who is experiencing post-traumatic stress disorder (PTSD). Which of the following manifestations should the healthcare professional expect?
- A. Hyperactivity
- B. Hypervigilance
- C. Restlessness
- D. Avoidance of social situations
Correct Answer: B
Rationale: Hypervigilance is a common manifestation of PTSD characterized by heightened alertness and fear of danger. This heightened state of awareness can lead to irritability, difficulty concentrating, and sleep disturbances. Choices A, C, and D are incorrect. Hyperactivity is not typically associated with PTSD; restlessness may be present but is not the primary manifestation, and avoidance of social situations is more commonly seen in conditions like social anxiety disorder rather than PTSD.
A healthcare professional is preparing to administer a blood transfusion. What is the healthcare professional's first action?
- A. Check the client's temperature
- B. Verify that the client's blood type matches the blood product
- C. Administer the blood through an IV push
- D. Ensure the blood is warmed before administration
Correct Answer: B
Rationale: The healthcare professional's first action before administering a blood transfusion should be to verify that the client's blood type matches the blood product. This step is crucial to ensure compatibility and prevent potentially severe transfusion reactions. Checking the client's temperature (Choice A) is important but not the first action in this scenario. Administering the blood through an IV push (Choice C) is incorrect as blood transfusions are typically administered as a slow infusion. Ensuring the blood is warmed before administration (Choice D) is not the first action and is not a standard practice in blood transfusions.
What should a healthcare professional assess in a patient presenting with symptoms of a stroke?
- A. Assess facial drooping
- B. Monitor speech difficulties
- C. Evaluate arm weakness
- D. Check for time of onset of symptoms
Correct Answer: A
Rationale: When assessing a patient with suspected stroke symptoms, it is crucial to check for facial drooping as it can be a sign of facial nerve weakness, which is a common indicator of stroke. While monitoring speech difficulties and evaluating arm weakness are also important assessments in stroke cases, they are secondary to facial drooping. Checking for the time of onset of symptoms is essential to determine eligibility for time-sensitive treatments like thrombolytic therapy, but when prioritizing assessments, facial drooping takes precedence.
A healthcare provider is reviewing the medical record of a client who is scheduled for surgery. Which of the following findings should the provider report?
- A. White blood cell count of 8,000/mm³
- B. Potassium level of 4.0 mEq/L
- C. Creatinine level of 1.0 mg/dL
- D. Hemoglobin level of 12 g/dL
Correct Answer: C
Rationale: An elevated creatinine level indicates impaired kidney function, which may affect the client's ability to undergo surgery. The other laboratory values (white blood cell count, potassium level, and hemoglobin level) are within normal ranges and do not directly impact the client's readiness for surgery.