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A nurse is transporting a client who has pneumonia and is on droplet precautions to radiology. Which of the following safety measures should the nurse take while transporting the client?
- A. The client should wear a mask during transport.
- B. The nurse should wear a mask during transport.
- C. The nurse should wear a gown during transport.
- D. The client should wear a gown during transport.
Correct Answer: A
Rationale: The client wearing a mask during transport prevents the spread of droplet pathogens, consistent with droplet precautions for pneumonia.
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A nurse is preparing to administer warfarin to a client who has chronic atrial fibrillation. Which of the following laboratory values should the nurse monitor prior to administering the medication?
- A. Hct
- B. INR
- C. BUN
- D. LDL
Correct Answer: B
Rationale: INR (International Normalized Ratio) is monitored for warfarin therapy to assess clotting time and ensure therapeutic anticoagulation levels.
A nurse is reinforcing teaching with a client who is premenopausal. Which of the following statements by the nurse is appropriate regarding breast self-examinations?
- A. Perform breast self-examinations during the middle of your cycle.
- B. Perform breast self-examinations while lying on your side.
- C. Use small, circular motions, working vertically up and down across the breast.
- D. Use the palm of your hand to detect the presence of any large masses under the skin.
Correct Answer: C
Rationale: Using small, circular motions in a vertical pattern is the correct technique for breast self-examination, making this an appropriate statement.
A nurse is caring for a client who is 6 hr postoperative following a bowel resection. Which of the following findings is the priority for the nurse to report?
- A. The client arouses easily but quickly falls back asleep.
- B. There is 20 mL of dark red drainage from the wound drainage device over the past 4 hr.
- C. There is 60 mL of dark yellow urine from the indwelling urinary catheter over the past 4 hr.
- D. The client reports a pain level of 6 on a scale from 0 to 10 at the incision site.
Correct Answer: A
Rationale: Difficulty staying awake 6 hours post-op suggests potential respiratory depression or neurological issues, a priority to report.
A nurse is assisting in the care of a client who is in the emergency department (ED) following a ski accident.
Nurses' Notes
Vital Signs
Diagnostic Results
Day 1:
Client brought to the emergency department (ED) following a fall that occurred while downhill skiing. Client states they fell when turning to avoid hitting another skier. Client reports feeling a severe, sudden pain of the right leg upon falling. Right leg was immobilized at the scene and the client transported to the ED.
Client states they were wearing a helmet while skiing. Client reports no headache or loss of consciousness.
Client reports pain as 10 on a scale of 0 to 10 to the right lower leg just below the knee and is unable to bear weight.
Right proximal tibia ecchymotic and swollen below the knee. Area is painful to touch. Open area noted on skin with bone visible. Right knee appears displaced. Left pedal pulses 3+, foot warm with intact movement and sensation. Right pedal pulses 1+, foot cool to palpation with minimal movement and reduced sensation.
The nurse is collecting data on the client. Which of the following findings require follow up?
- A. Findings of right lower extremity assessment
- B. Pain level
- C. Level of consciousness
- D. Oxygen saturation
- E. Right pedal pulses
- F. Temperature
- G. X-ray results
Correct Answer: A,B,E
Rationale: Right lower extremity findings (swelling, open wound), severe pain, and weak right pedal pulses indicate potential fracture or vascular compromise needing follow-up.
A nurse is caring for a client who is postoperative. For which of the following findings should the nurse suspect the client is experiencing a deep-vein thrombosis?
- A. Muscle spasms
- B. Absent pedal pulse
- C. Numbness of the affected extremity
- D. Warmth of the affected extremity
Correct Answer: D
Rationale: Warmth is a classic sign of deep-vein thrombosis due to inflammation and blood flow changes in the affected area.