Nokea
A nurse is assessing a client who has a urinary catheter. The nurse notes the client's IV tubing is kinked and the urinary catheter bag is lying next to the client in bed. The nurse should identify that the client is at risk for which of the following conditions?
- A. Neurogenic bladder
- B. Infection
- C. Skin breakdown
- D. Pistolate
Correct Answer: B
Rationale: The correct answer is B: Infection. The kinked IV tubing and the urinary catheter bag lying next to the client in bed can lead to contamination of the catheter system, increasing the risk of a urinary tract infection. The kinked tubing can cause backup of urine, leading to bacterial growth, while the catheter bag being on the bed can introduce pathogens to the catheter. Infections can result in serious complications for the client if not addressed promptly. The other choices, A: Neurogenic bladder, C: Skin breakdown, and D: Pistolate, are not directly related to the scenario presented and do not pose an immediate risk based on the information provided.
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A nurse is caring for a client who has acute angina. Which of the following actions should the nurse take first?
- A. Measure blood pressure.
- B. Administer aspirin.
- C. Administer nitroglycerin.
- D. Initiate IV access.
Correct Answer: B
Rationale: The correct answer is B: Administer aspirin. Aspirin helps to reduce platelet aggregation and prevent further clot formation in clients with acute angina, thus reducing the risk of myocardial infarction. Administering aspirin should be the first action as it addresses the immediate risk of clot formation and helps improve blood flow to the heart muscle.
Measuring blood pressure (A) can be important but is not the priority in this situation. Administering nitroglycerin (C) is important for symptom relief but does not address the underlying cause. Initiating IV access (D) may be necessary later for further interventions, but it is not the first priority.
A nurse is providing discharge teaching to a client who reports that they cannot afford their prescribed medication. Which of the following statements should the nurse make?
- A. I can arrange for a social worker to talk with you before you leave.'
- B. I can contact the occupational therapist to schedule a home visit.'
- C. Contact your pharmacy to inquire about a different medication.'
- D. You should ask your provider to prescribe a cheaper medication.'
Correct Answer: A
Rationale: The correct answer is A: "I can arrange for a social worker to talk with you before you leave." This option is the most appropriate as it addresses the client's financial constraints by offering assistance in accessing support services. A social worker can help the client explore options for medication assistance programs, financial aid, or community resources. Option B is incorrect as it does not directly address the client's medication affordability issue. Option C suggests switching medications without considering the client's specific needs. Option D places the burden on the client to navigate the healthcare system for cost-effective solutions. Option A is the best choice as it prioritizes addressing the client's financial barriers through appropriate referral and support.
A nurse is admitting a client who has arthritis pain and reports taking ibuprofen several times daily for 3 years. Which of the following tests should the nurse monitor?
- A. Serum calcium
- B. Stool for occult blood
- C. Fasting blood glucose
- D. Urine for white blood cells
Correct Answer: B
Rationale: The correct answer is B: Stool for occult blood. Long-term use of ibuprofen can lead to gastrointestinal bleeding, which may not always present with visible blood in the stool. Monitoring for occult blood helps detect this potential side effect early. Choices A, C, and D are not directly related to the adverse effects of ibuprofen use. Serum calcium is not typically affected by ibuprofen. Fasting blood glucose monitoring is more relevant for medications affecting glucose metabolism. Urine for white blood cells is not a common test for monitoring the side effects of ibuprofen.
A nurse is assessing a client who received a purified protein derivative (PPD) skin test 48 hr ago and notes erythema with induration of 13 mm at the injection site. Which of the following instructions should the nurse provide to the client?
- A. You will need to have the skin test annually.
- B. You will need to return in 48 hours for re-evaluation.
- C. Your test will need to be repeated at this time.
- D. You will need to follow up with your provider.
Correct Answer: D
Rationale: The correct answer is D: "You will need to follow up with your provider." The nurse should instruct the client to follow up with their provider because an induration of 13 mm at 48 hours post-PPD indicates a positive result for tuberculosis exposure. Follow-up is necessary to determine if treatment or further evaluation is needed. Choice A is incorrect because annual skin tests are not necessary unless there is ongoing exposure or risk factors. Choice B is incorrect as the client does not need to return in 48 hours for re-evaluation since the test has already been read at 48 hours. Choice C is incorrect as repeating the test is not necessary when a positive result is already present.
A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 minutes after the infusion begins. Which of the following actions should the nurse take first?
- A. Collect a urine sample.
- B. Check the client's vital signs.
- C. Stop the infusion.
- D. Administer oxygen to the client.
Correct Answer: C
Rationale: The correct answer is C: Stop the infusion. The client's symptoms suggest a transfusion reaction, which could be life-threatening. Stopping the infusion is the priority to prevent further harm. Checking vital signs can wait, as immediate action is needed. Collecting a urine sample is not urgent in this situation. Administering oxygen is not indicated unless the client shows signs of respiratory distress, which is not mentioned in the scenario.