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A nurse is admitting a client who has meningococcal meningitis. What should the nurse do first?
- A. Initiate droplet precautions
- B. Start intravenous antibiotics
- C. Perform a complete assessment
- D. Notify the healthcare provider
Correct Answer: A
Rationale: Initiating droplet precautions is crucial to prevent the spread of infection, especially in cases of meningococcal meningitis.
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A nurse is preparing to perform a routine abdominal assessment for a client. Which action should the nurse take?
- A. Perform palpation before auscultation
- B. Perform percussion before auscultation
- C. Perform palpation after auscultation
- D. Perform inspection after auscultation
Correct Answer: C
Rationale: The correct order for an abdominal assessment is inspection, auscultation, percussion, and then palpation.
A nurse is completing an admission assessment for a client who has hearing loss. What action should the nurse take?
- A. Speak loudly to the client
- B. Use written communication to assist with communication
- C. Avoid eye contact while speaking
- D. Use sign language without an interpreter
Correct Answer: B
Rationale: Using written communication can help ensure that the client understands the information being conveyed.
A nurse is performing a focused assessment on a client who has a history of COPD and is experiencing dyspnea. Which of the findings should the nurse expect?
- A. Flaring of the nostrils
- B. Normal respiratory rate
- C. Clear lung sounds
- D. Decreased work of breathing
Correct Answer: A
Rationale: Flaring of the nostrils indicates increased respiratory effort, common in clients with dyspnea due to COPD.
A nurse is in the emergency department monitoring the hydration status of a client receiving oral rehydration. What should the nurse intervene for?
- A. Heart rate 120/min
- B. Urine output 30 mL/hour
- C. Blood pressure 110/70 mmHg
- D. Skin turgor is normal
Correct Answer: A
Rationale: A heart rate of 120/min may indicate dehydration or inadequate hydration, prompting the need for IV fluid replacement.
A nurse is reviewing information about advance directives with a newly admitted client. Which of the following statements by the client indicates an understanding of the teaching?
- A. I understand that I can change my mind anytime
- B. I have a living will that outlines my wishes when I am unable to make a decision
- C. I need to inform my family about my wishes
- D. I don't need to worry about advance directives right now
Correct Answer: B
Rationale: Having a living will indicates the client understands that it outlines their wishes regarding medical treatment when they are unable to make decisions.