Nokea
A nurse is assessing a patient in the rehab unit at shift change. The patient has suffered a TBI 3 weeks ago. Which of the following is the most distinguishing characteristic of a neurological disturbance?
- A. LOC (level of consciousness)
- B. Short term memory
- C. #NAME?
- D. #NAME?
Correct Answer: A
Rationale: LOC is the most critical indicator of impaired neurological capabilities.
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The nurse is caring for a client with a history of breast cancer.
- A. Which symptom should the nurse report immediately for a client with a history of breast cancer?
- B. Mild fatigue after chemotherapy.
- C. A new lump in the axillary region.
- D. Occasional nausea.
- E. Hair loss.
Correct Answer: B
Rationale: A new lump in the axillary region may indicate lymph node metastasis, requiring immediate evaluation. Fatigue, nausea, and hair loss are expected chemotherapy side effects.
The nurse is caring for a person who has a nasogastric tube attached to drainage. Which complaint by the client needs to be reported to the charge nurse?
- A. Dry mouth
- B. Weak muscles
- C. Sore throat
- D. Irritated nose
Correct Answer: C
Rationale: A sore throat may indicate nasogastric tube complications like erosion or infection, requiring evaluation. Dry mouth, weakness, or nasal irritation are expected.
A six-year-old boy comes to the outpatient clinic for a routine exam. His mother is concerned because her son often talks to an 'imaginary best friend.'
The nurse should advise the mother to
- A. insist that her son play more often with other children.
- B. tell her son that this friend is not a real person.
- C. allow her son to engage in imaginary play.
- D. encourage her son to explain his friend to her.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) doesn't recognize play with imaginary friends as normal developmental state (2) may create anxiety in child (3) correct-normal for 4- to 6-year-old children (4) may create anxiety in child
The nurse is making patient assignments on the obstetrical unit.
Which of the following patients should the nurse assign to an RN who has been reassigned to the obstetrical unit from outpatient surgery?
- A. A patient at 16 weeks gestation admitted with hyperemesis receiving IV fluids.
- B. A patient at 26 weeks gestation in premature labor receiving terbutaline (Brethine).
- C. A patient at 32 weeks gestation with a placenta previa and ruptured membranes.
- D. A patient at 37 weeks gestation with pregnancy-induced hypertension and epigastric pain.
Correct Answer: A
Rationale: Strategy: LPN/LVN and 'pulled' RN receive stable patients with expected outcomes. (1) correct-monitor IV therapy, administer antiemetics and nutritional supplements (2) monitor patient's response to medication and the status of the fetus (3) prepare for delivery, closely monitor fetal response (4) indicates impending seizures, prepare for delivery
The nurse is monitoring a client’s EKG strip and notes coupled premature ventricular contractions greater than 10 per minute.
- A. Which medication should the nurse expect to administer for a client with coupled PVCs greater than 10 per minute?
- B. Atropine sulfate (Atropine) IV.
- C. Isoproterenol (Isuprel) IV.
- D. Verapamil (Calan) IV.
- E. Lidocaine hydrochloride (Xylocaine) IV.
Correct Answer: D
Rationale: Lidocaine is the drug of choice for frequent or coupled PVCs, as it suppresses ventricular arrhythmias that could lead to ventricular tachycardia. Atropine treats bradycardia, isoproterenol is used for heart block, and verapamil is a calcium-channel blocker for supraventricular arrhythmias.