Nokea
A nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse? A client with
- A. a Dopamine drip IV with vital signs monitored every 5 minutes
- B. a myocardial infarction that is free from pain and dysrhythmias
- C. a tracheotomy of 24 hours in some respiratory distress
- D. a pacemaker inserted this morning with intermittent capture
Correct Answer: B
Rationale: This client is the most stable with minimal risk of complications or instability. The nurse can utilize basic nursing skills to care for this client, making it suitable for a nurse from another unit.
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A client with congestive heart failure is newly admitted to home health care. The nurse discovers that the client has not been following the prescribed diet. What would be the most appropriate nursing action?
- A. Discharge the client from home health care because of noncompliance
- B. Notify the provider of the client's failure to follow prescribed diet
- C. Discuss diet with the client to learn the reasons for not following the diet
- D. Make a referral to Meals-on-Wheels
Correct Answer: C
Rationale: Discuss diet with the client to learn the reasons for not following the diet. When new problems are identified, it is important for the nurse to collect accurate assessment data. Before reporting findings to the provider, it is best to have a complete understanding of the client's behavior and feelings as a basis for future teaching and intervention.
A nurse who is assigned to the emergency department needs to understand that gastric lavage is a priority in which situation?
- A. An infant who has been identified as suffering from botulism
- B. A toddler who has eaten a number of ibuprofen tablets
- C. A preschooler who has swallowed powdered plant food
- D. A school aged child who has taken a handful of vitamins
Correct Answer: A
Rationale: Botulinum toxin is a neurotoxin that causes muscular paralysis. Gastric lavage is a priority to remove the toxin from the stomach before it is absorbed.
Which of these clients is the priority for the nurse to report to the public health department within the next 24 hours?
- A. An infant with a positive culture of stool for Shigella
- B. An elderly factory worker with a lab report that is positive for acid-fast bacillus smear
- C. A young adult commercial pilot with a positive histopathological examination from an induced sputum for Pneumocystis carinii
- D. A middle-aged nurse with a history of varicella zoster virus and with crops of vesicles on an erythematous base that appear on the skin
Correct Answer: B
Rationale: Tuberculosis is a reportable disease because persons who had contact with the client must be traced and often must be treated with chemoprophylaxis for a designated time.
All of the following clients are in need of an emergency assessment except:
- A. a bleeding client who has an injury from falling debris.
- B. an unresponsive client.
- C. a client with an old injury.
- D. a pregnant woman with imminent delivery.
Correct Answer: C
Rationale: The client with an old injury does not need an emergency assessment because this is not a life-threatening or new situation or condition.
When teaching a 10 year-old child about their impending heart surgery, which form of explanation meets the developmental needs of this age child?
- A. Provide a verbal explanation just prior to the surgery
- B. Provide the child with a booklet to read about the surgery
- C. Introduce the child to another child who had heart surgery 3 days ago
- D. Explain the surgery using a model of the heart
Correct Answer: D
Rationale: Explain the surgery using a model of the heart. According to Piaget, the school age child is in the concrete operations stage of cognitive development. Using a model to explain the surgery meets the child’s developmental needs for concrete and visual learning.