Nokea
A nurse has received report on the day's clients. In planning morning rounds, which client is the priority to see?
- A. a new admission with a UTI and fever
- B. a client who is NPO for surgery later in the morning
- C. a client complaining of nausea after eating breakfast
- D. a client recently complaining of shortness of breath
Correct Answer: D
Rationale: Shortness of breath indicates a potential respiratory or cardiac issue, making this client the priority for immediate assessment.
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A client seen in the emergency department for influenza asks for an antibiotic prescription. Which of the following guidelines are important in helping the client decrease the risk of developing an antibiotic-resistant infection? Select all that apply.
- A. Stop taking antibiotics as soon as symptoms subside.
- B. Do not take antibiotics for viral infections, as they do no good.
- C. Do not take preventive antibiotics to avoid infection.
- D. Follow prescription directions when taking antibiotics.
- E. Take the same antibiotic for every infection.
Correct Answer: B,C,D
Rationale: Avoid antibiotics for viral infections (B), avoid prophylactic antibiotics (C), and follow prescription directions (D) reduce resistance. Stopping early (A) or reusing antibiotics (E) promotes resistance.
A client with terminal lung cancer is admitted to the unit. A family member asks the nurse, 'How much longer will it be?' Which response by the nurse is most appropriate?
- A. This must be a terrible situation for you.
- B. I don't know. I'll call the doctor.
- C. I cannot say exactly. What are your concerns at this time?
- D. Don't worry, it will be very soon.
Correct Answer: C
Rationale: This response acknowledges the family's concern, provides an honest answer, and opens the conversation to address their specific worries, promoting therapeutic communication.
The nurse is working with a nursing student to administer an enema solution to a client. The client states she feels painful cramping. The nurse should intervene by
- A. squeezing the enema bag so the flow rate is faster.
- B. explaining to the client that this is a normal feeling and continuing with the enema.
- C. clamping the tube for 1 minute and then starting the enema at a slower rate.
- D. discontinuing the enema until the provider can order a PRN pain medication.
Correct Answer: C
Rationale: Painful cramping during an enema suggests too-rapid administration. Clamping briefly and slowing the rate reduces discomfort.
The nurse is caring for a client with bipolar disorder. The client has been manipulating some of the staff and other clients in order to get her way. Which actions by the nurse are appropriate in managing this client? Select all that apply.
- A. giving support when the client exhibits positive behaviors
- B. setting clear limits and communicating expected behaviors
- C. role playing with the client to demonstrate appropriate behaviors
- D. treating the client more like a friend in order to show respect for her as a person
- E. giving the client small gifts, such as extra dessert, in order to encourage appropriate behavior
Correct Answer: A,B,C
Rationale: Appropriate actions include reinforcing positive behaviors (A), setting clear limits (B), and role-playing (C) to promote appropriate interactions. Treating as a friend (D) or giving gifts (E) blurs boundaries and encourages manipulation.
The nurse is assessing a newborn 24 hours after birth. Which of the following findings would require further evaluation?
- A. Heart rate of 140 beats per minute.
- B. Respiratory rate of 40 breaths per minute.
- C. Presence of milia on the nose.
- D. Caput succedaneum crossing the suture line.
Correct Answer: C
Rationale: milia are normal, but persistent or widespread milia may indicate other issues; other findings are within normal limits for a newborn