Nokea
A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?
- A. A client who has epidural analgesia and weakness in the lower extremities
- B. A client who has a hip fracture and a new onset of tachypnea
- C. A client who has sinus arrhythmia and is receiving cardiac monitoring
- D. A client who has diabetes mellitus and an HbA1c of 6.8%
Correct Answer: B
Rationale: The correct answer is B. The nurse should assess the client with a hip fracture and new onset of tachypnea first. Tachypnea in this client could indicate a potential complication such as a pulmonary embolism, which is a life-threatening condition requiring immediate intervention. Assessing this client first allows for prompt identification and management of any emergent issues. Clients with epidural analgesia and lower extremity weakness (choice A) may indicate a neurological concern but are not as urgent as tachypnea in a client with a hip fracture. Sinus arrhythmia with cardiac monitoring (choice C) and diabetes mellitus with an HbA1c of 6.8% (choice D) do not present immediate life-threatening situations that require immediate assessment compared to the client with a hip fracture and tachypnea.
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Which of the following statements should the nurse include in the teaching?
- A. A nurse will draw blood from your baby's inner elbow.
- B. Your baby will be given 2 ounces of water to drink prior to the test.
- C. This test should be performed after your baby is 24 hours old.
- D. This test will be repeated when your baby is 2 months old.
Correct Answer: C
Rationale: Newborn genetic screening is most accurate when performed after the baby is 24 hours old.
A nurse is caring for a 2-year-old toddler. Which of the following food choices should the nurse recommend to promote independence in eating?
- A. Banana slices
- B. Grapes
- C. Hot dog
- D. Popcorn
Correct Answer: A
Rationale: The correct answer is A: Banana slices. Toddlers at the age of 2 are developing their fine motor skills and independence. Banana slices are easy for toddlers to pick up and eat independently, promoting their self-feeding skills. Grapes pose a choking hazard due to their size and shape. Hot dogs are also a choking hazard as they can easily get stuck in a toddler's throat. Popcorn is a common choking hazard for young children due to its hard texture. Therefore, recommending banana slices will not only promote independence in eating but also ensure safety for the toddler.
A nurse is caring for a client whose partner recently died. The nurse sits with the client to provide comfort. Which of the following ethical principles is the nurse demonstrating?
- A. Fidelity
- B. Veracity
- C. Autonomy
- D. Beneficence
Correct Answer: D
Rationale: The correct answer is D: Beneficence. Beneficence is the ethical principle that involves doing good and promoting the well-being of others. By sitting with the client to provide comfort after the loss of their partner, the nurse is demonstrating beneficence by showing compassion and support. Fidelity (A) relates to keeping promises and being faithful to commitments. Veracity (B) is about truthfulness and honesty. Autonomy (C) refers to respecting the client's right to make their own decisions. The other choices are not directly related to the nurse's action of providing comfort in this context.
A nurse is caring for a client who has given informed consent for electroconvulsive therapy. Just before the procedure, the client tells the nurse she is considering not going forward with the treatment. Which of the following statements by the nurse is appropriate?
- A. Most people who have this procedure feel better following the treatment.
- B. Your doctor wouldn't have ordered this treatment unless it was necessary.â€
- C. It's okay to be nervous before this treatment.
- D. You don't have to go through with the treatment.
Correct Answer: D
Rationale: Rationale: Option D is correct because it respects the client's autonomy and right to make decisions about their treatment. The client has the right to refuse treatment, even after giving initial consent. It is important for the nurse to support the client's decision without coercion.
Summary:
A: Incorrect. This statement does not address the client's current decision to refuse treatment.
B: Incorrect. This statement undermines the client's autonomy by implying they should follow the doctor's orders.
C: Incorrect. While acknowledging the client's feelings is important, it does not address the client's decision to refuse treatment.
D: Correct. Respects the client's autonomy and decision-making.
E, F, G: Not applicable.
A nurse is performing a skin assessment on a client who has dark skin. Which of the following locations on the client's body should the nurse observe to assess for cyanosis?
- A. Sacrum
- B. Palms of the hands
- C. Shoulders
- D. Area of trauma
Correct Answer: B
Rationale: The correct answer is B: Palms of the hands. In dark-skinned individuals, cyanosis may not be as apparent in typical areas like lips or nail beds. Palms of the hands are a reliable location to assess for cyanosis as they have less melanin and blood vessels close to the surface, making cyanosis more visible. The other choices (A: Sacrum, C: Shoulders, D: Area of trauma) are not ideal locations to assess for cyanosis as they are less likely to show accurate signs due to differences in skin thickness, blood vessel distribution, and melanin content.