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A nurse is collecting data from a client who is perimenopausal. Which of the following findings is the priority for the nurse to report to the provider?
- A. Difficulty sleeping
- B. Hot flashes
- C. Vaginal dryness
- D. Urinary frequency
Correct Answer: D
Rationale: Perimenopause brings hormonal shifts, but urinary frequency stands out it may signal a UTI, bladder issue, or pelvic pathology, requiring urgent evaluation over typical symptoms. Difficulty sleeping and hot flashes stem from estrogen fluctuations, common and manageable with lifestyle changes. Vaginal dryness, also hormonal, responds to lubricants or estrogen therapy, not immediate concern. Frequency, however, risks infection or renal complications older women often present atypically (e.g., confusion), per geriatric guidelines. Using ABCs, elimination issues outrank comfort, driving prompt reporting for diagnostics (e.g., urinalysis), preventing progression, making it the priority finding.
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A nurse is caring for a client who has returned to the unit following a cardiac catheterization using a femoral approach. Which of the following methods should the nurse use to monitor for complications?
- A. Palpate the client's brachial pulses and compare bilaterally.
- B. Check for jugular vein distention while the client is supine.
- C. Check the client's blood pressure while the client lies supine, sits, and stands.
- D. Palpate the client's pedal pulses and compare bilaterally.
- E. Monitor respiratory rate.
- F. Check for chest pain.
- G. Assess skin temperature.
Correct Answer: D
Rationale: Pedal pulses assess for femoral artery complications like hematoma or occlusion.
A nurse in a long-term care facility is assisting with the plan of care for a client who has late-stage Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?
- A. Turn the client every 2 hr to prevent pressure ulcers.
- B. Place a mirror in the client's room for reality orientation.
- C. Offer the client written instructions for performing oral hygiene.
- D. Ask the client open-ended questions to encourage conversation.
Correct Answer: A
Rationale: Late-stage Alzheimer's reduces mobility, heightening pressure ulcer risk. Turning every 2 hours redistributes weight, preserving skin integrity, a preventive standard (e.g., NPUAP guidelines). Mirrors confuse patients unable to recognize themselves, increasing agitation. Written instructions are futile severe cognitive loss prevents comprehension; physical cues work better. Open-ended questions overwhelm, as verbal ability is minimal; simple prompts suit better. Repositioning addresses a physical priority, reduces complications like infection, and upholds care quality, making it the essential action.
A nurse is contributing to the plan of care for a client who has HIV. Which of the following interventions should the nurse plan to include?
- A. Provide a diet of pureed foods.
- B. Encourage fluids with meals.
- C. Offer small, frequent meals.
- D. Suggest fresh fruits and vegetables.
Correct Answer: C
Rationale: Clients with HIV often experience nutritional challenges due to symptoms like nausea, fatigue, or opportunistic infections, necessitating a tailored dietary plan. Option A, pureed foods, is suited for swallowing difficulties, not a general HIV need, so it's inappropriate. Option B, encouraging fluids with meals, may dilute gastric juices and worsen digestion or appetite, countering nutritional goals. Option C is correct small, frequent meals help maintain energy, combat weight loss, and accommodate reduced appetite or early satiety common in HIV, supporting immune function and medication tolerance. Option D, fresh fruits and vegetables, sounds healthy but risks infection (e.g., from unwashed produce) in immunocompromised clients, requiring caution or cooking instead. Small, frequent meals align with evidence-based HIV care, optimizing calorie intake and nutrient absorption without overwhelming the digestive system, making it the most effective and safe intervention for this population.
A nurse is caring for a client who has a prescription for propranolol for the treatment of atrial fibrillation. Which of the following actions should the nurse take?
- A. Administer the medication with an antacid.
- B. Instruct the client to expect increased hair growth.
- C. Withhold the medication if the systolic blood pressure is less than 90 mm Hg
- D. Request a dosage increase if the apical heart rate is less than 60/min.
- E. Monitor for weight gain.
- F. Check respiratory rate.
- G. Administer with food.
Correct Answer: C
Rationale: Propranolol, a beta-blocker, should be withheld if BP is low to avoid hypotension; antacids don't interact, and hair growth isn't an effect.
A nurse is preparing to perform a sterile dressing change for a client who has a stage III pressure ulcer. Which of the following actions should the nurse plan to take?
- A. Prepare the sterile dressing supplies 30 min before the dressing change.
- B. Don sterile gloves before removing the dressing,
- C. Disinfect the wound bed with alcohol before applying tape.
- D. Offer the client pain medication before the procedure.
Correct Answer: D
Rationale: Offering pain medication beforehand reduces discomfort during the dressing change for a stage III ulcer. Supplies should be prepared just before, sterile gloves are used after removal, and alcohol isn't used on open wounds.