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 actions should the nurse take?
- A. Assign the child to a negative air pressure room.
- B. Use droplet precautions when caring for the child
- C. Assess the child for Koplik spots
- D. Administer aspirin to the child for fever.
Correct Answer: A
Rationale: Negative pressure rooms prevent airborne spread of varicella.
A nurse is admitting a client who has schizophrenia. The client state nurse to state?"I'm hearing voices. Which of the following responses is the priority for the nurse to state"
- A. What are the voices telling you?
- B. I realize the voices are real to you, but I don't hear anything.â€
- C. Have you taken your medication today?â€
- D. How long have you been hearing the voices?
Correct Answer: A
Rationale: The correct answer is A: "What are the voices telling you?" This response shows active listening and encourages the client to express their thoughts, helping the nurse assess the content and potential danger of the voices. Choice B dismisses the client's experience, choice C focuses on medication compliance rather than immediate safety, and choice D is relevant but does not address the immediate concern.
Select the 5 actions the nurse should take.
- A. Provide frequent rest periods for the client.
- B. Restrict the client's sodium intake
- C. Advise the client to avoid the use of soap and alcohol-based lotions
- D. Place the client on a low-carbohydrate diet
- E. Place the client under contact isolation.
- F. Instruct the client to avoid blowing their nose forcefully
- G. Assess the client's level of orientation
Correct Answer: A,B,C,E,F,G
Rationale: The correct actions the nurse should take are A, B, C, E, F, and G. A: Providing rest periods promotes healing. B: Restricting sodium intake is crucial for certain health conditions. C: Avoiding soap and alcohol-based lotions can prevent skin irritation. E: Placing the client under contact isolation is necessary to prevent the spread of infection. F: Instructing the client to avoid blowing their nose forcefully prevents injury. G: Assessing the client's level of orientation is essential for monitoring their mental status. Other choices are incorrect because a low-carbohydrate diet (D) is not mentioned, and it is not a priority action in this scenario.
The nurse should monitor the client for which of the following complications?
- A. Contractions
- B. Hypertension
- C. Epigastric pain
- D. Vomiting
Correct Answer: A
Rationale: Contractions can indicate preterm labor, a potential complication after amniocentesis.
Which of the following actions should the nurse take first?
- A. Determine the client's Glasgow Coma Scale score
- B. Insert an indwelling urinary catheter for the client.
- C. Administer mannitol IV bolus to the client
- D. Prepare the client for an MRI of the brain.
Correct Answer: A
Rationale: The correct answer is A: Determine the client's Glasgow Coma Scale (GCS) score. This is the priority action as it helps assess the client's level of consciousness and neurological status quickly. It guides further interventions and treatment decisions. Inserting an indwelling urinary catheter (B) or administering mannitol IV bolus (C) may be needed but assessing neurological status comes first. Preparing for an MRI (D) is important but not the initial step.