Nokea
A nurse receives report on a group of clients. Which client should the nurse assess first?
- A. A preschool-age child with a harsh cough, expiratory wheezes, and mild intercostal retractions
- B. A toddler playing with small toys who appears in distress, has circumoral cyanosis, and cannot speak
- C. A toddler with a barking cough, infrequent inspiratory stridor, and oxygen saturation of 94% on room air
- D. An infant with an axillary temperature of 100.1 F (37.8 C) who is tugging at the left ear
Correct Answer: B
Rationale: The toddler with circumoral cyanosis, distress, and inability to speak suggests a potential airway obstruction, a life-threatening emergency requiring immediate assessment. Other clients show less acute symptoms.
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A client is admitted to the hospital with a diagnosis of deep vein thrombosis. During the initial assessment, the client complains of sudden shortness of breath. The SaO2 is 87. The priority nursing assessment at this time is
- A. bowel sounds
- B. heart rate
- C. peripheral pulses
- D. lung sounds
Correct Answer: D
Rationale: Lung sounds are critical assessments at this point. The nurse should be alert to crackles or a pleural friction rub, highly suggestive of a pulmonary embolism.
The nurse is reinforcing teaching for a client with atrial fibrillation who has a new prescription for warfarin. The nurse should instruct the client to avoid excess or inconsistent intake of which of the following foods? Select all that apply.
- A. red meat
- B. bananas
- C. broccoli
- D. spinach
- E. kale
Correct Answer: C,D,E
Rationale: Broccoli, spinach, and kale are high in vitamin K, which can antagonize warfarin's anticoagulant effect. Consistent intake is key, but excess can reduce effectiveness. Red meat and bananas have minimal vitamin K and don't significantly affect warfarin.
The nurse is caring for a man who had a transsphenoidal hypophysectomy earlier today. He says he has to spit a lot. What nursing action is essential?
- A. Ask him to blow his nose.
- B. Do a glucose test on his mouth secretions.
- C. Have him rinse his mouth with water.
- D. Ask him if he needs an antiemetic.
Correct Answer: B
Rationale: Excessive spitting may indicate cerebrospinal fluid (CSF) leak, which contains glucose; testing secretions confirms this serious complication.
The nurse is reinforcing discharge teaching on a client with polycythemia vera. Which would be included in the teaching plan?
- A. Avoid large crowds.
- B. Keep the head of the bed elevated at night.
- C. Wear socks and gloves when going outside.
- D. Know the signs and symptoms of thrombosis.
Correct Answer: D
Rationale: Polycythemia vera increases blood viscosity, raising the risk of thrombosis. Teaching the client to recognize signs and symptoms of thrombosis, such as swelling or pain in extremities, is critical. Avoiding large crowds relates to infection risk, not thrombosis. Elevating the head of the bed is unrelated, and wearing socks and gloves is more relevant for conditions like Raynaud's.
The nurse is providing home care for an immobile client who has a stage IV decubitus ulcer that is not healing. Assuming that all of the following are available, which person would be most appropriate to consult regarding care of the wound?
- A. Physician
- B. Physical therapist
- C. IV therapist
- D. Enterostomal therapist
Correct Answer: D
Rationale: An enterostomal therapist specializes in wound and ostomy care, making them the most appropriate consultant for managing a non-healing stage IV decubitus ulcer. Physicians oversee care, physical therapists focus on mobility, and IV therapists manage infusions.