Nokea
A nurse receives the taped change-of-shift report for assigned clients and prioritizes client rounds. In what order should the nurse assess these clients?
- A. A client with an endotracheal tube transferred out of the intensive care unit that day.
- B. A client with type 2 diabetes who had a cerebrovascular accident 4 days ago.
- C. A client with cellulitis of the left lower extremity with a fever of 100.8°F (38.2°C).
- D. A client receiving D5W I.V. at 125 mL/hour with 75 mL remaining.
Correct Answer: A,C,B,D
Rationale: The client with a new endotracheal tube (A) is highest priority due to airway risk. The febrile client with cellulitis (C) is next for infection monitoring. The stroke client (B) is stable 4 days post-event. The I.V. fluid client (D) is lowest priority.
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A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. The nurse should:
- A. Count the rate to be sure that ventilations are deep enough to be sufficient.
- B. Notify the physician of the client's breathing pattern.
- C. Increase the rate of ventilations.
- D. Increase the tidal volume on the ventilator.
Correct Answer: B
Rationale: Cluster breathing, a sign of neurological deterioration, requires immediate physician notification for evaluation and possible intervention. Adjusting ventilator settings without medical orders is inappropriate, and simply counting the rate does not address the underlying issue.
What should the nurse monitor in a client receiving baclofen?
- A. Blood pressure.
- B. Spasticity levels.
- C. Blood glucose.
- D. Respiratory rate.
Correct Answer: B
Rationale: Spasticity levels are monitored to evaluate the effectiveness of baclofen in reducing muscle spasticity.
In which areas of the United States is the incidence of tuberculosis highest?
- A. Rural farming areas.
- B. Inner-city areas.
- C. Areas where clean water standards are low.
- D. Suburban areas with significant industrial pollution.
Correct Answer: B
Rationale: Inner-city areas have higher tuberculosis incidence due to crowding, poverty, and limited healthcare access. Rural, low-water-standard, and suburban areas have lower rates.
A client has a leg immobilized in traction. Which of the following activities demonstrated by the client indicate that the client understands actions to take to prevent muscle atrophy?
- A. The client adducts the affected leg every 2 hours.
- B. The client rolls the affected leg away from the body's midline twice per day.
- C. The client performs isometric exercises to the affected extremity three times per day.
- D. The client asks the nurse to add a 5-lb weight to the traction for 30 minutes/day.
Correct Answer: C
Rationale: Isometric exercises maintain muscle strength without moving the immobilized leg.
Prevention of skin breakdown and maintenance of skin integrity among older clients is important because they are at greater risk secondary to:
- A. Altered balance.
- B. Altered protective pressure sensation.
- C. Impaired hearing ability.
- D. Impaired visual acuity.
Correct Answer: B
Rationale: Older adults have reduced pressure sensation due to thinner skin and nerve changes, increasing the risk of skin breakdown and pressure ulcers.