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A nurse is reinforcing discharge teaching for a client who had a cerebrovascular accident (CVA) and requires assistance to perform their ADLs. Which of the following statements should the nurse provide?
- A. You will not become fatigued when you use assistive devices.
- B. Plan to hire a home care aid to perform all of your ADLs.
- C. Install grab bars in your shower to assist with your balance.
- D. Place a towel in the shower to prevent slipping
Correct Answer: C
Rationale: Grab bars enhance safety and independence in the shower post-CVA. Fatigue is possible, full assistance isn't always needed, and a towel could be a slip hazard.
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A nurse is reviewing vital signs obtained by an assistive personnel on a group of clients. The previous vital signs for each of the clients were obtained 4 hr earlier. Which of the following changes should the nurse identify as the priority finding?
- A. Heart rate change from 110/min to 68/min
- B. Respiratory rate change from 12/min to 20/min
- C. Blood pressure change from 118/78 mm Hg to 86/50 mm Hg
- D. Temperature change from 36.6°C (97.9°F) to 38.8°C (101.9°F)
Correct Answer: C
Rationale: Using the ABCs, blood pressure dropping from 118/78 to 86/50 mm Hg signals potential shock or hypoperfusion, a circulation emergency requiring immediate assessment. Heart rate falling from 110 to 68 could reflect recovery (e.g., post-tachycardia) or bradycardia, but without symptoms, it's less urgent. Respiratory rate rising from 12 to 20 suggests compensation or distress, but circulation trumps breathing in acuity here. Temperature jumping to 38.8°C indicates fever, possibly infection, but hemodynamic instability is more immediately life-threatening. A systolic drop to 86 mm Hg risks organ perfusion, aligning with triage priorities hypotension could stem from bleeding, dehydration, or sepsis, needing rapid provider notification. This finding drives urgent intervention, making it the nurse's top concern.
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.
A nurse is contributing to the plan of care for a client who is postoperative following a fasciotomy. Which of the following interventions should the nurse plan to include?
- A. Provide a diet of pureed foods.
- B. Assist the client to the restroom 30 min after meals.
- C. Offer small, frequent meals.
- D. Instruct the client to avoid sexual intercourse until the cervix is healed.
Correct Answer: C
Rationale: Post-fasciotomy care focuses on pain management, wound healing, and monitoring for complications like infection or compartment syndrome recurrence, not dietary or reproductive restrictions. Offering small, frequent meals supports nutritional needs without overloading the stomach, aiding recovery by maintaining energy for tissue repair, especially if appetite is reduced from pain or medications. A pureed diet is unnecessary unless swallowing is impaired, which isn't indicated here fasciotomy addresses limb pressure, not GI issues. Assisting to the restroom post-meals relates to bowel training, irrelevant to this surgical context. Avoiding sexual intercourse applies to pelvic procedures like colposcopy, not a limb fasciotomy. Small, frequent meals align with postoperative principles, promoting healing and comfort, making it the most relevant intervention for this client's plan of care, enhancing overall recovery without complicating the surgical focus.
A nurse enters a client's room and sees smoke coming from the trash can next to the client's bed. Which of the following actions should the nurse take first?
- A. Pull the fire alarm panel.
- B. Obtain a fire extinguisher.
- C. Remove the client from the room.
- D. Close the door to the client's room.
Correct Answer: C
Rationale: In a fire emergency, the RACE protocol (Rescue, Alarm, Contain, Extinguish) guides nursing actions, prioritizing safety. Option C is correct removing the client from the room first ensures their immediate safety from smoke inhalation or burns, the primary risk in this scenario. Option A, pulling the alarm, is crucial but secondary; the client's life takes precedence over alerting others. Option B, obtaining an extinguisher, delays rescue and assumes the nurse can safely fight the fire, which may not be feasible with smoke present. Option D, closing the door, helps contain the fire but traps the client in danger if done first. Rescuing the client aligns with the ethical duty to protect life, addresses the imminent threat of smoke (a leading cause of fire-related death), and allows subsequent steps (alarm, containment) to follow safely. This sequence reflects standard fire safety training and hospital policy, making it the nurse's first action.
A nurse is collecting data from an older adult client. Which of the following findings should indicate to the nurse that the client has a bladder infection?
- A. WBC count 9,000/mm³ (5,000 to 10,000/mm³)
- B. Temperature 37.3° C (99.1° F)
- C. Changed mental status
- D. Diminished reflexes
Correct Answer: C
Rationale: Older adults with bladder infections (UTIs) often lack classic symptoms, presenting with altered mental status confusion or lethargy from systemic inflammation or bacteremia, per geriatric care standards. Normal WBC (9,000/mm³) doesn't rule out UTI; leukocytosis isn't always present early. A slight fever (37.3°C) supports infection but isn't definitive alone. Diminished reflexes tie to aging or neurology, not UTI. Mental status change is a red flag prompting urinalysis and antibiotics preventing sepsis, making it the strongest indicator in this population.