Nokea
A nurse in a health clinic is collecting data from an older adult client. Which of the following information in the client's history increases her risk for osteoporosis?
- A. The client is a gardener.
- B. The client is lactose intolerant.
- C. The client has a glass of red wine every evening
- D. The client walks 3.2 km (2 mi) daily.
- E. The client smokes daily.
- F. The client has a family history of osteoporosis.
- G. The client takes corticosteroids long-term.
Correct Answer: B
Rationale: Lactose intolerance limits calcium intake, a key risk factor for osteoporosis; gardening and walking are protective, and moderate wine has minimal impact.
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A nurse is reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will perform breast exams the day my period begins.
- B. I will perform breast exams every other month.
- C. It is common for the skin on my breasts to dimple.
- D. It is common for one breast to be larger than the other.
Correct Answer: D
Rationale: It's normal for one breast to be slightly larger than the other, and this statement reflects an accurate understanding of breast anatomy. Dimpling can be a sign of concern, and exams should be done monthly, about a week after the period starts, not on the first day or every other month.
Vital Signs
Day 1:
• Temperature 36°C (96.8°F)
• Blood pressure 140/80 mm Hg
• Heart rate 98/min
• Respiratory rate 24/min
• Oxygen saturation 97% on room air
Day 2, 0800:
• Temperature 37°C (98.6°F)
• Blood pressure 122/60 mm Hg
• Heart rate 85/min
• Respiratory rate 18/min
• Oxygen saturation 98% on room air
A nurse is assisting in the plan of care for the client who has compartment syndrome. Which potential prescription is anticipated?
- A. Open the splint
- B. Obtain a urinalysis
- C. Place the client on NPO status
- D. Place the client's right leg in a dependent position
Correct Answer: A, D
Rationale: Compartment syndrome requires relieving pressure to restore perfusion. Opening the splint (or cast) reduces external compression, an anticipated step pre-fasciotomy if tightness contributes to ischemia, per orthopedic protocols. Urinalysis checks for myoglobinuria from muscle breakdown, a diagnostic aid, but not immediate relief. NPO status prepares for surgery, a later consideration after pressure relief. A dependent leg position increases venous pooling, worsening swelling and pressure contraindicated here. Opening the splint directly addresses the mechanical cause, buying time for surgical evaluation, aligning with emergency management (e.g., AAOS guidelines), making it the expected prescription to prioritize limb viability.
A nurse is reviewing the results of a client's fecal occult blood screening test. Which of the following findings from the client's history should the nurse identify as potentially causing a false-positive result?
- A. The client consumed citrus juice 3 days before the test.
- B. The client takes ibuprofen for headaches.
- C. The client had a hemorrhoidectomy 1 year ago.
- D. The client has a history of breast cancer.
Correct Answer: B
Rationale: Fecal occult blood tests detect heme, but false positives arise from non-colonic bleeding. Ibuprofen, an NSAID, irritates the GI mucosa, causing microbleeds that mimic colorectal sources, a known confounder clients are advised to stop it pre-test. Citrus juice may cause false negatives (vitamin C interferes with guaiac reaction), not positives, and 3 days minimizes impact. A hemorrhoidectomy 1 year ago, healed, doesn't bleed unless recurrent, not suggested. Breast cancer doesn't affect GI bleeding unless metastatic, unlikely here. Ibuprofen's GI effect aligns with testing pitfalls (e.g., ACG guidelines), making it the likely false-positive source to identify.
A nurse is preparing to perform a blood glucose test. After performing hand hygiene and donning gloves, in which order should the nurse perform the following actions to obtain a capillary blood sample?
- A. Allow the site to dry.
- B. Pierce the puncture site quickly.
- C. Squeeze the site gently to obtain a blood droplet.
- D. Cleanse the site with an antiseptic swab.
- E. Apply blood to the test strip.
Correct Answer: D,A,B,C,E
Rationale: The order is: Cleanse with antiseptic (D), allow to dry (A), pierce (B), squeeze for blood (C), and apply to strip (E) for an accurate, sterile sample.
A nurse is reinforcing teaching about environmental modifications in the home with a family member of a client who has Alzheimer's disease. Which of the following information should the nurse include in the teaching?
- A. Leave the television on.
- B. Install locks at the top of doors.
- C. Place throw rugs on the floor.
- D. Schedule alternate caregivers.
Correct Answer: B
Rationale: Locks at the top of doors prevent wandering, a safety concern in Alzheimer's. TV can agitate, rugs are a fall risk, and caregiver scheduling isn't an environmental modification.