Nokea
A nurse is caring for a 90-year-old client who has been bedridden at home for two weeks. Which of the following is not an expected finding due to immobility?
- A. A decrease in bone density
- B. Loss of short-term memory
- C. Atelectasis
- D. High serum calcium level
Correct Answer: B
Rationale: Immobility causes bone density loss, atelectasis, and high serum calcium due to bone resorption, but short-term memory loss is not directly related to immobility.
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The emergency department charge nurse was notified of a mass shooting at a nearby shopping mall. The nurse should take which action to prepare for the surge in clients? Select all that apply.
- A. Work to arrange timely discharge and admission for appropriate clients.
- B. Establish a holding area for discharged clients not able to go home.
- C. Modify the nurse/client ratio to accommodate the surge levels.
- D. Instruct staff to switch from electronic to paper documentation.
- E. Prepare to provide frequent updates to local media.
Correct Answer: A,B
Rationale: Timely discharges/admissions and a holding area optimize resources. Modifying nurse ratios, switching to paper documentation, or media updates are not primary actions.
The nurse is caring for a client three hours postoperative following a laparoscopic appendectomy. Which of the following client data indicates the client is ready for discharge home?
- A. Positive gag reflex
- B. Hypoactive bowel sounds
- C. Blood pressure 90/60 mm Hg
- D. Incisional pain '2' on a scale of 0 to 10
- E. Urinary output of 240 mL since surgery
Correct Answer: A,D,E
Rationale: A positive gag reflex indicates airway protection, mild incisional pain (2/10) suggests adequate pain control, and sufficient urinary output (240 mL) indicates renal function, all supporting discharge readiness. Low blood pressure (90/60 mm Hg) suggests instability, and hypoactive bowel sounds are expected but not a discharge criterion.
The nurse is caring for a post-operative client at risk for a pressure ulcer. Which intervention should the nurse include in the plan of care?
- A. Apply sequential compression devices
- B. Apply an extra sheet to the bed
- C. Position the client on a donut pillow
- D. Encourage the consumption of high-protein foods
Correct Answer: D
Rationale: High-protein foods support tissue repair and collagen synthesis, critical for preventing pressure ulcers in at-risk clients. Sequential compression devices prevent thromboembolism, not pressure ulcers. An extra sheet does not reduce pressure, and donut pillows can increase pressure on surrounding tissues, worsening the risk.
The nurse is caring for a client immediately following hypophysectomy. The nurse should position the client
- A. Trendelenburg
- B. Side-lying
- C. high-Fowler's
- D. Reverse Trendelenburg
Correct Answer: C
Rationale: High-Fowler’s position (head elevated 30–45 degrees) is recommended post-hypophysectomy to reduce intracranial pressure and prevent cerebrospinal fluid leakage. Trendelenburg and reverse Trendelenburg could increase pressure or disrupt surgical site healing, and side-lying is less effective for this purpose.
The following scenario applies to the next 1 items
Item 1 of 1
Nurses' Notes
Orders Current Medications Laboratory>
1700: 73-year-old male reports explosive, watery, foul-smelling diarrhea that started two days ago. The client reports intermittent abdominal cramping that occurs with watery diarrhea. He says his wife made him come in to get medical attention because he was starting to 'feel weak' and 'probably dehydrated.' The client was assessed to have: a sunken eye appearance, dry, flaky skin, and thready peripheral pulses. VS: Oral Temperature 98° F (36.7° C), pulse 86/minute, respirations 16/minute, blood pressure 113/68 mm Hg, oxygen saturation 96% on room air.
1725: Stool sample of foul-smelling diarrhea sent to the lab.
1830: Laboratory result received. Physician notified of results.
The nurse reviews the nurses' notes, orders, current medications, and laboratory data for a 73-year-old male with explosive, watery, foul-smelling diarrhea. Based on the clinical data, select five (5) nursing interventions the nurse should implement.
- A. Obtain a prescription for metronidazole
- B. Place a droplet precautions sign outside the room
- C. Educate the client to wash surfaces at home with bleach
- D. Remove the alcohol-based sanitizers from the room
- E. Request a prescription for a cleansing enema
- F. Encourage the intake of by mouth (PO) fluids
- G. Review hand hygiene measures with the client
Correct Answer: A,C,D,F,G
Rationale: Suspected C. difficile requires metronidazole, bleach cleaning, removal of alcohol-based sanitizers, fluid intake encouragement, and hand hygiene education. Droplet precautions and enemas are not indicated.