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A nurse is performing a risk assessment for a client. Which of the following factors should the nurse identify as increasing the clients risk for falls?
- A. The client had cataract surgery 1 day ago.
- B. The client uses a hearing aid.
- C. The client has a history of hypertension.
- D. The client has a history of constipation.
Correct Answer: A
Rationale: Correct Answer: A. The client had cataract surgery 1 day ago.
Rationale: Cataract surgery can lead to temporary visual impairment, affecting depth perception and balance, increasing fall risk.
Summary:
B: Using a hearing aid does not directly increase fall risk.
C: History of hypertension does not directly increase fall risk for falls.
D: History of constipation does not directly increase fall risk for falls.
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A nurse is caring for a client who is receiving vancomycin intermittent IV bolus therapy for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following findings is an indication to the nurse that the client is experiencing an adverse effect of the medication?
- A. The client reports ringing in the ears.
- B. The client is becoming flushed.
- C. The client reports increased thirst.
- D. The client has a decreased urine output.
Correct Answer: B
Rationale: The correct answer is B: The client is becoming flushed. Flushing is a common adverse effect of vancomycin, indicating a possible allergic reaction or infusion reaction. Flushing can be a sign of red man syndrome, a severe reaction to vancomycin. The nurse should monitor closely and report this finding to the healthcare provider.
Incorrect Answer Rationale:
A: The client reports ringing in the ears - this is a potential adverse effect of vancomycin, but not as critical as flushing.
C: The client reports increased thirst - this is not typically associated with vancomycin adverse effects.
D: The client has a decreased urine output - this may indicate nephrotoxicity, a known side effect of vancomycin, but flushing is more indicative of an immediate adverse reaction.
A nurse is assessing a clients ECG strip and notes an irregular heart rate of 98/min with no clear P waves. Which of the following cardiac dysrhythmias should the nurse document?
- A. Sinus bradycardia
- B. Atrial fibrillation
- C. Ventricular tachycardia
- D. First-degree heart block
Correct Answer: B
Rationale: The correct answer is B: Atrial fibrillation. In atrial fibrillation, the heart rate is irregular and fast (98/min), and there are no clear P waves on the ECG strip, which aligns with the findings in the scenario. Atrial fibrillation is characterized by chaotic electrical activity in the atria, leading to an irregular heart rate. Sinus bradycardia (A) is characterized by a slow heart rate with normal P waves. Ventricular tachycardia (C) is a fast heart rhythm originating in the ventricles with distinct QRS complexes. First-degree heart block (D) is identified by a prolonged PR interval but should still have clear P waves. Other choices are not relevant. In this case, the absence of clear P waves and irregular heart rate point towards atrial fibrillation as the correct dysrhythmia to document.
A nurse is caring for a client immediately following intubation with an endotracheal (ET) tube. Which of the following methods should the nurse identify as the most reliable for verifying placement of the ET tube?
- A. Observing for symmetrical chest rise and fall
- B. Auscultating bilateral breath sounds
- C. Using an end-tidal COâ‚‚ detector
- D. Checking for condensation in the ET tube
Correct Answer: C
Rationale: The correct answer is C: Using an end-tidal CO2 detector. This method is the most reliable for verifying ET tube placement because it directly measures the presence of CO2 in exhaled breath, confirming that the tube is in the trachea. This is crucial to prevent inadvertent esophageal intubation. Observing for symmetrical chest rise and fall (A) can be misleading as it can occur even with esophageal intubation. Auscultating bilateral breath sounds (B) can also be unreliable as breath sounds may be heard even if the tube is in the esophagus. Checking for condensation in the ET tube (D) is not a reliable method for verifying placement as condensation can occur regardless of tube placement.
A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following findings should the nurse identify as a manifestation of type 1 diabetes?
- A. Ketones in the urine
- B. Weight gain
- C. Hypotension
- D. Decreased hunger
Correct Answer: A
Rationale: The correct answer is A: Ketones in the urine. In type 1 diabetes, the body cannot produce insulin, leading to high blood sugar levels and breakdown of fats for energy, resulting in ketones in the urine. Weight gain (B) is unlikely as type 1 diabetes is associated with weight loss. Hypotension (C) is not a typical manifestation. Decreased hunger (D) is more commonly seen in type 2 diabetes.
A nurse is caring for a client who recently assumed the role of caregiver for their aging parents who have chronic illnesses. The nurse should identify that which of the following statements by the client indicates acceptance of the role change?
- A. I feel overwhelmed and unsure if I can handle this responsibility.
- B. I changed the floor plan of our home to accommodate my fathers wheelchair.
- C. I wish my siblings would help more with our parents care.
- D. I often feel resentful about the extra responsibilities.
Correct Answer: B
Rationale: The correct answer is B. Changing the floor plan of the home to accommodate the father's wheelchair demonstrates acceptance of the caregiving role. This action shows that the client is willing to make necessary adjustments for their parents' needs, indicating a commitment to the role change.
A: Feeling overwhelmed and unsure indicates resistance to the role change.
C: Wishing for siblings' help suggests a desire to share responsibilities, not necessarily acceptance.
D: Feeling resentful points towards negative emotions, which do not align with acceptance.