Nokea
A nurse is reinforcing teaching with a client who will be wearing a Holter monitor for the next 24 hr. Which of the following information should the nurse include?
- A. You will need to record daily activities in a diary.
- B. You should remove the electrodes when you go to bed.
- C. You can bathe while wearing the electrodes.
- D. You should not have sexual intercourse while the monitor is in place.
- E. Avoid exercise entirely.
- F. Keep the monitor in water.
- G. Remove it if it beeps.
Correct Answer: A
Rationale: Recording activities helps correlate symptoms with heart activity; electrodes stay on, and bathing is avoided.
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History and Physical
1000:
Client reports generalized weakness and increased fatigue over the past few months.
Client states they become short of breath after climbing a flight of stairs and are having difficulty keeping up with their grandchildren.
History of rheumatoid arthritis. Reports taking naproxen 500 mg twice a day.
Client reports they follow a vegan diet.
Denies pain or discomfort.
Bilateral breath sounds clear and present throughout.
Mucous membranes pale.
Apical pulse rapid, regular.
Diagnostic Results
1000:
Hct 24% (37% to 47%)
Hgb 8 g/dL (12 to 16 g/dL)
RBC count 3 x 10 ⁶ pL (4.2 to 5.4 x 10 ⁶ pL)
Ferritin 8 ng/mL (10 to 150 ng/mL)
WBC count 9,000/mm ³ (5,000 to 10,000/mm ³)
Platelet count 180,000/mm ³ (150,000 to 400,000/mm ³)
Vitamin B ₁₂ 159 pg/mL (160 to 950 pg/mL)
Complete the following sentence by using the lists of options.The first action the nurse should take is to followed by (Client with low Hct, Hgb, vegan diet)
- A. reinforce education about nutritional supplements
- B. collecting data about nutritional intake
- C. administer IV fluids
- D. notify the provider
- E. monitor vital signs
- F. prepare for transfusion
- G. document findings
Correct Answer: B,A
Rationale: Collecting nutritional data identifies deficiencies (e.g., B12, iron from vegan diet), followed by education on supplements.
A nurse is assisting with the care of a client who has a closed-chest tube drainage system. Which of the following actions should the nurse take?
- A. Replace the unit when the drainage chamber is full.
- B. Monitor for at least 150 mL of drainage every hour.
- C. Clamp the tube for 30 min every 8 hr.
- D. Pin the tubing to the client's bed sheets.
Correct Answer: A
Rationale: Chest tube systems remove pleural air or fluid, requiring functionality. Replacing the unit when full prevents backpressure or overflow, maintaining drainage and lung re-expansion, per manufacturer and infection control standards (e.g., CDC). Monitoring 150 mL/hr is excessive sudden high output signals hemorrhage, not routine care. Clamping risks tension pneumothorax by trapping air/fluid, only done briefly for specific checks (e.g., air leak). Pinning tubing prevents dislodgement, but full chamber replacement is the proactive maintenance action. This ensures system efficacy, prevents complications like atelectasis, and aligns with respiratory care priorities, making it the nurse's key responsibility.
A nurse is collecting data from a client who has a subdural hematoma following a motor-vehicle crash. For which of the following findings should the nurse identify that the client is experiencing an increase in intracranial pressure?
- A. The client has a delayed response to verbal commands.
- B. The client has ecchymosis around the eyes.
- C. The client is unable to remember details of the motor-vehicle crash.
- D. The client reports ringing in the ears.
Correct Answer: A
Rationale: Delayed verbal response indicates rising intracranial pressure (ICP) affecting brain function. Ecchymosis and amnesia are hematoma signs, and ringing ears isn't specific to ICP.
A nurse is providing first aid for a client who has a minor burn on one hand, which of the following actions should the nurse take? (Select all that apply.)
- A. Maintain skin integrity over the blisters.
- B. Apply ice to the larger blisters.
- C. Administer ibuprofen for pain.
- D. Run cool water over the affected area.
- E. Allow the affected area to remain open to air.
Correct Answer: A,C,D
Rationale: Maintaining blister integrity prevents infection (A), ibuprofen relieves pain (C), and cool water reduces heat and pain (D). Ice can damage tissue, and open air may increase infection risk.
A nurse is assisting in the care of the client who has iron deficiency anemia. Which of the following statements indicate the client understands the instructions?
- A. I should increase green leafy vegetables in my diet.
- B. The iron supplement might cause my stools to be black.
- C. I should expect to have swelling in my feet.
- D. I will take my iron supplement 1 hour before a meal.
Correct Answer: B
Rationale: Iron supplements oxidize in the gut, often turning stools black due to unabsorbed iron a normal, expected effect clients should recognize to avoid alarm. Green leafy vegetables (e.g., spinach) boost dietary iron, but oxalates limit absorption, making this less indicative of supplement-specific teaching. Swelling in feet isn't a typical iron effect edema suggests heart or kidney issues, not anemia treatment. Taking iron 1 hour before meals aids absorption, a good practice, but the question emphasizes understanding therapy outcomes. Black stools confirm the client grasps a common, visible side effect, aligning with education goals (e.g., managing expectations), ensuring adherence and reducing unnecessary worry, making it the clearest sign of comprehension.