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A middle-aged client reports a sudden onset of seeing flashing lights and floating spots. Which is the best nursing action?
- A. Initiate a referral for ophthalmic evaluation as soon as possible.
- B. Advise the client to maintain normal activities, but avoid contact sports until the spots resolve
- C. Instruct the client to rest, and report to the emergency department if eye pain develops.
- D. Tell the client to apply warm, moist compresses and notify the healthcare provider if there is no improvement.
Correct Answer: A
Rationale: Flashing lights and floaters suggest retinal detachment, requiring urgent ophthalmic evaluation.
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The nurse is evaluating the effectiveness of the incentive spirometer implemented in the client's plan of care. Which outcome statement best describes the effectiveness of the incentive spirometer?
- A. Client's breath sounds are clear to auscultation bilaterally.
- B. Client exhibits a frequent productive cough.
- C. Client demonstrates proper use of an incentive spirometer.
- D. Client reports using the incentive spirometer every hour while awake.
Correct Answer: A
Rationale: Clear breath sounds indicate effective lung expansion, the primary goal of incentive spirometry, unlike cough, technique, or compliance.
While assessing a client following lithotripsy with stent insertion, which data indicates to the nurse that the procedure was successful?
- A. Stone fragments are collected when straining the client's urine.
- B. Client denies urinary frequency, urgency, or dysuria.
- C. Urine is pale pink with no observable blood clots.
- D. Serum creatinine and blood urea nitrogen (BUN) levels are within normal limits.
Correct Answer: A
Rationale: Collecting stone fragments directly confirms the success of lithotripsy in breaking down the stone, unlike symptom relief or lab values.
History and Physical
Nurses' Notes
Orders
Imaging Studies
The client is a young male who appears to be 25 to 30 years old. He was found unconscious on a sidewalk by a jogger who was passing by. The jogger called an ambulance, and the emergency medical technicians (EMTS) transported the client to the hospital. The client is arousable but unable to say what his name is or what happened to him. A STAT head computed tomography (CT) scan in the emergency department showed no abnormalities, so the client will be admitted to the medical floor for observation and further tests.
The nurse identifies that the client is having a tonic clonic seizure. The oxygen saturation is 40% and the respiratory rate is 4 breaths/minute. The nurse calls for help and 2 other nurses enter the room. Which 3 interventions should be performed first?
- A. Place pillows around the bed rails to provide padding.
- B. Watch the seizure activity and document the time and client movement.
- C. Manually ventilate the client with a bag-valve mask (BVM).
- D. Stop the IV fluids.
- E. Increase the supplemental oxygen to 10 L/minute via nasal cannula.
- F. Begin chest compressions.
Correct Answer: B,C,E
Rationale: Ventilation, oxygen increase, and seizure monitoring address hypoxia and safety during a tonic-clonic seizure.
After being transferred from the emergency department to a medical unit, a client vomits into an emesis basin. The nurse observes the emesis as seen in the picture. Which assessment should the nurse complete first?
- A. Obtain current vital signs.
- B. Measure abdominal girth.
- C. Observe for flushing
- D. Auscultate breath sounds.
Correct Answer: A
Rationale: Vital signs assess hemodynamic stability, critical for potential gastrointestinal bleeding indicated by coffee-ground emesis, prioritizing over other assessments.
A client with an acute exacerbation of rheumatoid arthritis (RA) has localized pain and inflammation of the fingers and feet, swelling, redness, restricted joint motion, and reports feeling fatigued. Which nursing problem has the highest priority for this client?
- A. Fatigue related to disease exacerbation.
- B. Pain related to joint inflammation
- C. Impaired physical mobility related to joint pain.
- D. Self-care deficit related to disease progression.
Correct Answer: B
Rationale: Pain is the primary symptom of RA exacerbation, impacting quality of life and requiring immediate management.