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A nurse in an assisted living facility is collecting data from an older adult client who fell in their room and hit their head on the dresser. Which of the following findings is the nurse's priority?
- A. Unable to repeat the names of three common objects the nurse names.
- B. Unable to answer a judgment question correctly.
- C. Unable to remember their adult children's names.
- D. Unable to remain fully awake while answering questions.
Correct Answer: D
Rationale: Inability to stay awake suggests a serious head injury (e.g., concussion or hemorrhage), making it the priority finding.
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A nurse is caring for a client who has a tracheostomy tube. Upon data collection, the nurse observes the client is restless and hears crackles in the lungs. Which of the following interventions should the nurse take?
- A. Perform suctioning.
- B. Instill saline into the tubing.
- C. Increase the humidification.
- D. Check the cuff pressure.
Correct Answer: A
Rationale: Restlessness and crackles in the lungs suggest secretions in the airway, and suctioning is the appropriate intervention to clear them in a client with a tracheostomy.
A nurse is collecting data from a client who underwent a thyroidectomy 4 hr ago. Which of the following client findings indicates a complication of the procedure?
- A. Soreness at the incision site
- B. Serosanguineous drainage on the dressing
- C. Report of sore throat
- D. Tingling of the fingers
Correct Answer: D
Rationale: Tingling of the fingers suggests hypocalcemia due to parathyroid gland damage during thyroidectomy, a potential complication.
A nurse is reinforcing teaching about ostomy care with a client who has a new colostomy. Which of the following findings should the nurse instruct the client to report to the provider?
- A. Soft, unformed stools
- B. Purplish stoma
- C. Noticeable stool odor
- D. Slight bleeding around the stoma
Correct Answer: B
Rationale: A purplish stoma indicates potential ischemia or poor blood supply, requiring prompt reporting to the provider.
A nurse is transporting a client who has pneumonia and is on droplet precautions to radiology. Which of the following safety measures should the nurse take while transporting the client?
- A. The client should wear a mask during transport.
- B. The nurse should wear a mask during transport.
- C. The nurse should wear a gown during transport.
- D. The client should wear a gown during transport.
Correct Answer: A
Rationale: The client wearing a mask during transport prevents the spread of droplet pathogens, consistent with droplet precautions for pneumonia.
A nurse is assisting with the transfer of a client from a medical-surgical unit to an intensive care unit following a change in status. Which of the following information should the nurse include in the transfer documentation?
- A. Current medication prescriptions
- B. Primary health problem
- C. Number of family members who have visited
- D. Admission vital signs from 1 week ago
- E. Scheduled times for dressing changes
Correct Answer: A,B,E
Rationale: Medications, primary problem, and dressing schedules are critical for continuity of care in the ICU; family visits and old vital signs are less relevant.