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A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?
- A. A client who is scheduled for a procedure in 1 hr
- B. A client who received a pain medication 30 min ago for postoperative pain
- C. A client who was just given a glass of orange juice far a low blood glucose level
- D. A client who has 100 mL of fluid remaining in his IV bag
Correct Answer: C
Rationale: The correct answer is C. The nurse should assess the client who just drank orange juice for a low blood glucose level first because hypoglycemia can lead to serious complications like seizures or loss of consciousness. Assessing and addressing the client's blood glucose level promptly is crucial to prevent harm.
Choice A is not the priority as the client scheduled for a procedure in 1 hour can wait for assessment until after the client with low blood glucose is evaluated.
Choice B, the client who received pain medication 30 minutes ago, can be assessed after the client with low blood glucose since the medication's effects have likely already taken place.
Choice D, the client with 100 mL of fluid remaining in the IV bag, can also wait for assessment as it does not pose an immediate threat to the client's health compared to low blood glucose.
Therefore, prioritizing the assessment of the client with low blood glucose is crucial to ensure their safety and well-being.
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Which of the following should the nurse identify as an expected finding?
- A. Weak femoral pulses
- B. Frequent nosebleeds
- C. Upper extremity hypotension
- D. Increased intracranial pressure
Correct Answer: A
Rationale: Coarctation of the aorta often results in weak or absent femoral pulses due to reduced blood flow to the lower extremities.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing.
- A. Instruct the client to avoid live vaccines, Instruct the client to use mild soaps for cleansing skin, Instruct the client to avoid foods high in purities, Instruct the client to apply tropical analgesics, Instruct the client to apply heat
- B. Systemic lupus erythematous, Osteoarithritis, Gout, Rheumatoid arthritis(RA)
- C. Uric acid level, ESH, Joint deformities, lymphadenopathy, ANA
Correct Answer:
Rationale: Gout presents with elevated uric acid levels.
A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence the nurse should follow to perform suctioning.(Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
- A. Apply suction while rotating the catheter.
- B. Rinse the catheter to remove secretions:
- C. Dan sterile gloves.
- D. Insert the catheter during the client's inspiration.
- E. Turn on the suction and set the pressure
Correct Answer: C,D,E,A,B
Rationale: To perform nasotracheal suctioning correctly, the nurse should follow these steps:
1. Dan sterile gloves (C): Ensures aseptic technique to prevent infection.
2. Insert the catheter during the client's inspiration (D): Reduces the risk of hypoxia and trauma.
3. Turn on the suction and set the pressure (E): Prepares the equipment for suctioning.
4. Apply suction while rotating the catheter (A): Maximizes removal of secretions.
5. Rinse the catheter to remove secretions (B): Ensures cleanliness of the catheter for next use.
Other choices are incorrect:
- F and G are not applicable in this sequence as they do not contribute to the safe and effective performance of nasotracheal suctioning.
Which of the following responses should the nurse make?
- A. It is always difficult caring for someone who is terminally ill.
- B. You should consider taking a sleeping pill before bed each night.
- C. I can give you information about respite care if you are interested.
- D. I am sure you're doing a great job taking care of your mother.
Correct Answer: C
Rationale: Respite care provides temporary relief for caregivers, which can improve their well-being.
A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care?(Select all that apply.)
- A. Give the client one simple direction at a time
- B. Refute the client's delusions using logic
- C. Allow the client to choose among a variety of activities each day
- D. Reinforce orientation to time, place, and person
- E. Establish eye contact when communicating with the client.
Correct Answer: A,D,E
Rationale: Correct Answer: A, D, E
Rationale:
A: Giving the client one simple direction at a time is essential for someone with dementia to reduce confusion and facilitate understanding.
D: Reinforcing orientation to time, place, and person helps maintain the client's sense of reality and reduce disorientation.
E: Establishing eye contact when communicating with the client enhances connection and understanding, aiding in effective communication.
Incorrect Choices:
B: Refuting the client's delusions using logic may lead to frustration and agitation, as individuals with dementia may not be able to understand or accept logical arguments.
C: Allowing the client to choose among a variety of activities each day may overwhelm them with choices, leading to increased confusion and agitation.