Nokea
A nurse is assessing several clients in a long-term health care facility. Which client is at highest risk for the development of decubitus ulcers?
- A. A 79-year-old malnourished client on bed rest
- B. An obese client who uses a wheelchair
- C. A client who had 3 episodes of incontinent diarrhea
- D. An 80-year-old ambulatory diabetic client
Correct Answer: A
Rationale: A malnourished client on bed rest is at the highest risk for developing decubitus ulcers due to a combination of factors such as poor nutritional status and immobility. Malnourished individuals have compromised skin integrity, making them more susceptible to pressure ulcers. Being on bed rest further exacerbates this risk as constant pressure on bony prominences can lead to tissue damage. Although the other choices may also be at risk for developing decubitus ulcers, the malnourished client on bed rest presents the highest risk due to the combination of malnutrition and immobility.
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A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client's room, the oxygen is running at 6 liters per minute, the client's color is flushed, and his respirations are 8 per minute. What should the nurse do first?
- A. Obtain a 12-lead EKG
- B. Place the client in high Fowler's position
- C. Lower the oxygen rate
- D. Take baseline vital signs
Correct Answer: C
Rationale: In a client with COPD, it is crucial to prevent carbon dioxide retention by avoiding high oxygen levels. As the client's oxygen is running at 6 liters per minute and he is showing signs of oxygen toxicity, such as flushed color and low respirations, the nurse's priority should be to lower the oxygen rate. This action helps prevent worsening the client's condition. Obtaining an EKG, placing the client in high Fowler's position, or taking baseline vital signs are important assessments but addressing the potential oxygen toxicity takes precedence in this scenario.
Which of these clients with associated lab reports is a priority for the nurse to report to the public health department within the next 24 hours?
- A. An infant with a positive stool culture for Shigella
- B. An elderly factory worker with a positive lab report for acid-fast bacillus smear
- C. A young adult commercial pilot with a positive histopathological examination for Pneumocystis carinii from an induced sputum
- D. A middle-aged nurse with a history of varicella-zoster virus and crops of vesicles on an erythematous base appearing on the skin
Correct Answer: B
Rationale: The correct answer is B because a positive acid-fast bacillus smear in an elderly factory worker suggests tuberculosis, a serious communicable disease that must be reported promptly to the public health department to prevent its spread. Choice A is incorrect as Shigella is an important pathogen, but it does not require immediate public health reporting. Choice C is incorrect because Pneumocystis carinii is an opportunistic pathogen and does not require urgent public health reporting. Choice D is incorrect as varicella-zoster virus causes chickenpox and shingles, both of which are not reportable diseases to the public health department.
A nurse is reinforcing teaching with a client who has constipation about a high-fiber diet. Which of the following foods should be included as sources of fiber? Select one that doesn't apply.
- A. Kidney beans
- B. Strawberries
- C. Peanut butter
- D. Whole wheat bread
Correct Answer: C
Rationale: The correct answer is C, Peanut butter. While kidney beans, strawberries, and whole wheat bread are high-fiber foods that help alleviate constipation, peanut butter is not a significant source of fiber. Peanut butter is more known for its protein and healthy fats content rather than being a good source of dietary fiber. Therefore, it should not be included as a primary recommendation for a high-fiber diet in the context of addressing constipation.
Which client calling the community health clinic would the nurse ask to come in that day to be seen by the health care provider?
- A. I started my period, and now my urine has turned bright red.
- B. I am a diabetic, and today I have been going to the bathroom every hour.
- C. I was started on medicine yesterday for a urinary infection. Now my lower belly hurts when I go to the bathroom.
- D. I went to the bathroom, and my urine looked very red, and it didn't hurt when I went.
Correct Answer: D
Rationale: The correct answer is D because bright red urine without pain suggests possible hematuria, which is a concerning symptom that requires immediate medical evaluation. Option A mentions bright red urine but also relates it to starting a period, which is less likely to be an urgent issue. Option B describes increased urination, which may indicate hyperglycemia but doesn't require immediate evaluation. Option C presents symptoms more related to a urinary tract infection that may not require urgent attention.
A nurse is caring for four clients. The nurse should observe which of the following clients for a risk of vitamin B6 deficiency?
- A. A client who has cystic fibrosis
- B. A client who has chronic alcohol use disorder
- C. A client who takes phenytoin for a seizure disorder
- D. A client who is prescribed rifampin for tuberculosis
Correct Answer: B
Rationale: Chronic alcohol use disorder can lead to vitamin B6 deficiency due to impaired absorption and increased excretion of the vitamin. While clients with cystic fibrosis may be at risk for fat-soluble vitamin deficiencies, such as vitamins A, D, E, and K, they are not specifically at high risk for vitamin B6 deficiency. Clients taking phenytoin are at risk for folate deficiency, not vitamin B6. Clients prescribed rifampin for tuberculosis are at risk for vitamin D deficiency, not vitamin B6.