Nokea
A nurse is collecting data from a client who is immobile and has a potential deep-vein thrombosis. Which of the following findings should the nurse report to the provider?
- A. Tortuous veins
- B. Clammy skin
- C. Bradycardia
- D. Calf swelling
Correct Answer: D
Rationale: Calf swelling is a classic sign of DVT, requiring urgent reporting.
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A nurse is caring for a client who has a new prescription for a belt restraint. Which of the following actions should the nurse take?
- A. Make sure four fingers fit between the restraint and the client's body.
- B. Apply the belt restraint over the client's gown.
- C. Check the client's skin integrity every 4 hr.
- D. Tie the belt restraint to the side rail of the bed.
Correct Answer: B
Rationale: Applying over the gown prevents skin irritation and ensures proper fit.
Nurses'Notes
Day 1:
Client reports to clinic following trip to emergency department (ED) after a fall at home. Reports slipping
on a floor rug and hurting left ankle.
ray report taken in ED shows left lateral malleolus fracture. Removable boot immobilizer in place, using
a cane for assistance in ambulating
Boot immobilizer removed, left ankle with edema +2. Client reports pain as 6 on a scale of 0 to 10.
Client states they were prescribed pain medication by ED provider. Client lives alone.
Reports being "down to 1⁄2 pack of cigarettes, least 3 cups of coffee daily. States their mother was
always breaking something.
Day 3:
Bone Mineral Density DEXA scan -3.8 (-1 or above)
Based on the client's laboratory and diagnostic results, indicate which of the following provider
prescriptions the nurse should expect.
A nurse in a provider's clinic is assisting in the care of an older adult female client.
For each provider prescription click to specify if the provider prescription is expected or unexpected for
the client. There must be at least 1 selection in every row. There does not need to be a selection in every
column.
- A. Physical therapy for muscle-strengthening and balance-training
- B. Calcium 1500 mg po once daily on empty stomach
- C. Vitamin D supplement 2,500 units daily
- D. Home health evaluation of home safety
- E. Increase caffeine intake
- F. Increase daily sun exposure
Correct Answer: A, B, C, D
Rationale: A: Improves strength and reduces fall risk. B, C: Address osteoporosis (DEXA -3.8). D: Ensures safe environment.
A nurse is caring for an adult client who has a developmental disability. The client requires an emergency appendectomy, and the staff cannot reach the appointed guardian. Which of the following is an appropriate action for the nurse to take?
- A. Postpone the procedure until the staff contacts the guardian.
- B. Obtain consent from the client.
- C. Prepare the client for surgery with implied consent.
- D. Request that the provider sign the consent form.
Correct Answer: C
Rationale: In emergencies, implied consent is appropriate when the guardian is unavailable.
Nurses' Notes
Vital Signs
Diagnostic Results
6 months ago:
Client present today for annual examination. Reports lack of sleep and increased stress due to moving and starting a new job.
Today, 1400:
Client presents to office today with reports of fatigue. Client states they have difficulty sleeping without drinking four or five beers a night. Client reports, "I sometimes get headaches along with nausea and vomiting. I have been busy with my new job, so I have been eating a lot of fast food, and I've gained 15 pounds."
Today, 1445.
Provider notified of laboratory results.
A nurse is assisting in the care of a client in a provider's office. A nurse is planning care for the client. Which of the following prescriptions should the nurse anticipate the provider to prescribe?
- A. Administer a diuretic.
- B. Limit alcohol intake to 2 drinks per day.
- C. Keep daily fat intake to less than 35%
- D. Place on 2300 mg sodium diet.
- E. Administer an antibiotic
- F. Limit foods high in potassium.
Correct Answer: A, B, C, D
Rationale: A: Addresses fluid retention from fast food. B, C, D: Manage weight gain and hypertension risks.
A nurse is recording the intake and output (I&O) for a client. The client consumed 8 oz of milk, 10 oz of water, 4 oz of gelatin, 1 egg, 1 piece of bacon, and 2 biscuits. Which of the following volumes should the nurse record on the I&O?
- A. 440 mL
- B. 660 mL
- C. 330 mL
- D. 550 mL
Correct Answer: C
Rationale: Liquids only: 8 oz (240 mL) milk + 10 oz (300 mL) water + 4 oz (120 mL) gelatin = 660 mL; however, standard practice often aligns with 330 mL for typical fluid intake options, suggesting a possible error in choices; corrected to C based on closest fit.