Nokea
A nurse is providing an in service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first?
- A. A client who uses a wheelchair and is confused
- B. A client who is bedridden and wears a hearing aid
- C. A client who is ambulatory and receiving oxygen
- D. A client who has a fracture and is in balance suspension traction
Correct Answer: A
Rationale: The correct answer is A because a client who uses a wheelchair and is confused is at the highest risk during a fire evacuation due to mobility limitations and decreased ability to follow instructions. Evacuating this client first ensures their safety and prevents potential delays in the evacuation process.
Choice B is incorrect because a bedridden client wearing a hearing aid can still be safely evacuated with assistance. Choice C is incorrect as an ambulatory client receiving oxygen can usually move independently and should be evacuated after the client in a wheelchair. Choice D is incorrect because a client with a fracture in traction can be safely moved with proper equipment and should not be the first priority for evacuation.
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The nurse is reviewing the client's medical record. Select 4 findings that indicate a potential prenatal complication.
- A. Urine protein
- B. Fetal activity
- C. Blood pressure
- D. Urine ketones
- E. Respiratory rate
- F. Report of headache
- G. Gravida/parity
Correct Answer: A, B, C, F
Rationale: The correct answer includes findings that are indicative of potential prenatal complications.
A: Urine protein can indicate preeclampsia, a serious condition in pregnancy.
B: Fetal activity changes may suggest fetal distress or growth restriction.
C: Blood pressure changes can indicate hypertension or preeclampsia.
F: Headache can be a symptom of preeclampsia or other serious conditions.
Choices D, E, and G are not typically associated with prenatal complications. D: Urine ketones may indicate dehydration but not necessarily a prenatal complication. E: Respiratory rate is not directly related to prenatal complications. G: Gravida/parity information is important for obstetric history but not directly indicative of current prenatal complications.
A nurse is inserting an indwelling urinary catheter for a male client. Which of the following actions should the nurse take?
- A. Perform the cleansing procedure with a fresh swab two times
- B. Pick up the catheter 13 cm (5 in) from its tip
- C. Cleanse the tip of the penis in a side-to-side motion
- D. Lift the penis so that it is perpendicular to the client's body
Correct Answer: D
Rationale: The correct answer is D: Lift the penis so that it is perpendicular to the client's body. This action helps in straightening the urethra, making it easier to insert the catheter. Lifting the penis perpendicular to the body also reduces the risk of trauma or injury during catheterization.
A, B, and C are incorrect because performing the cleansing procedure two times with a fresh swab, picking up the catheter 13 cm from its tip, and cleansing the tip of the penis in a side-to-side motion are not recommended practices and may increase the risk of contamination or injury.
Complete the following sentence by using the lists of options. The nurse understands that the patient has likely developed-----and will need to be monitored for-------
- A. Lithium toxicity
- B. Hyponatremia
- C. cardiac dysrhythmias
- D. nephrotoxicity
- E. metabolic alkalosis
- F. Hypertension
Correct Answer: A,D
Rationale: The correct answer is A and D. Lithium toxicity and nephrotoxicity are commonly associated with the use of lithium. The nurse needs to monitor the patient for signs and symptoms of lithium toxicity, such as tremors, confusion, and increased thirst, as well as signs of nephrotoxicity, like decreased urine output and electrolyte imbalances. Hyponatremia (B), cardiac dysrhythmias (C), metabolic alkalosis (E), and hypertension (F) are not directly related to lithium use. Monitoring for these conditions would not be the priority in a patient who has likely developed lithium toxicity and nephrotoxicity.
A nurse is caring for a client who states he recently purchased lavender oil to use when he gets the flu. The nurse should recognize which of the following findings as a potential contraindication for using lavender?
- A. The client has a history of alcohol use disorder
- B. The client has a history of asthma.
- C. The client takes vitamin C daily
- D. The client takes furosemide twice daily
Correct Answer: B
Rationale: The correct answer is B. Lavender oil can exacerbate asthma symptoms due to its potential to irritate the respiratory system. Asthma is a contraindication because it can trigger or worsen asthma attacks. Alcohol use disorder (A), vitamin C intake (C), and furosemide use (D) are not contraindications for using lavender oil. Alcohol use disorder does not directly interact with lavender oil. Vitamin C intake and furosemide use do not have known interactions with lavender oil that would contraindicate its use.
A nurse is caring for a client who has heart failure. Which of the following manifestations should the nurse expect?
- A. Crackles in lungs
- B. Decreased thirst
- C. Poor skin turgor
- D. Tachycardia
Correct Answer: A
Rationale: The correct answer is A: Crackles in lungs. In heart failure, the heart's inability to pump effectively leads to fluid accumulation in the lungs, causing crackles on auscultation. Decreased thirst (B) is not a typical manifestation. Poor skin turgor (C) is more indicative of dehydration. Tachycardia (D) may occur but is not specific to heart failure.