Nokea
A nurse is caring for a client with an exacerbation of chronic obstructive pulmonary disease (COPD) and a history of type 2 diabetes mellitus requiring insulin. The client has been prescribed prednisone. The nurse anticipates which need?
- A. Close monitoring for hypotension
- B. Gradually increasing the prednisone dose
- C. Increasing the insulin dose
- D. Monitoring and recording intake and output
Correct Answer: C
Rationale: Prednisone increases blood glucose, necessitating a higher insulin dose in diabetes. Hypotension is not a primary concern, prednisone is not typically titrated upward, and intake/output monitoring is less critical.
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The clinic nurse is reinforcing instructions to a client who will be wearing a Holter monitor for the next 24 hours. Which instructions are important to review with the client?
- A. How to transmit the readings over the phone
- B. Keep a diary of activities and any symptoms experienced
- C. Refrain from exercising while wearing the monitor
- D. The monitor may be removed only when bathing
Correct Answer: B
Rationale: Keeping a diary of activities and symptoms correlates events with cardiac readings, aiding diagnosis. Transmitting readings is not client responsibility, and Holter monitors are typically worn continuously, including during bathing.
The nurse is assessing for jaundice in a client who has dark skin. What is the best way to do this?
- A. Ask the client if his/her stool has changed color
- B. Look at the client's sclera
- C. Pinch the nail beds and observe the color
- D. Look at the client's fingers
Correct Answer: B
Rationale: The sclera (white of the eyes) reliably shows yellowing in jaundice, even in dark skin, unlike stool color, nail beds, or fingers, which are less specific.
The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate?
- A. Widening pulse pressure
- B. Pleural friction rub
- C. Distended neck veins
- D. Bradycardia
Correct Answer: C
Rationale: Distended neck veins. Cardiac tamponade causes venous congestion, leading to distended neck veins.
The nurse is caring for a client who is very demanding. She frequently rings the bell and asks to have her pillow fluffed or the water glass filled. Which response by the nurse will likely be most effective?
- A. Answer the bell quickly each time she rings
- B. Say, 'I do not have time to be in your room constantly.'
- C. Say, 'Why are you so upset?'
- D. Say, 'You seem concerned about something.'
Correct Answer: D
Rationale: Acknowledging potential underlying concerns invites the client to express needs, reducing demands. Constant responses reinforce behavior, and dismissive or confrontational responses escalate tension.
At a community health fair the blood pressure of a 62 year-old client is 160/96. The client states 'My blood pressure is usually much lower.' The nurse should tell the client to
- A. go get a blood pressure check within the next 48 to 72 hours
- B. check blood pressure again in 2 months
- C. see the health care provider immediately
- D. visit the health care provider within 1 week for a BP check
Correct Answer: A
Rationale: The blood pressure reading is moderately high with the need to have it rechecked in a few days. Although the client states it is 'usually much lower,' a concern exists for complications such as stroke. An immediate check by the provider of care is not warranted. Waiting 2 months or a week for follow-up is too long.