Nokea
After assisting a client with a lower gastrointestinal bleed back to bed, the nurse finds approximately 600 mL of frank red blood in the toilet. The client is pale and diaphoretic and reports dizziness. Which action should the nurse perform first?
- A. Document the output and vital signs
- B. Draw blood for hemoglobin and hematocrit
- C. Lower the head of the bed
- D. Notify the registered nurse
Correct Answer: C
Rationale: Significant bleeding (600 mL), pallor, diaphoresis, and dizziness suggest hypovolemia. Lowering the head of the bed improves cerebral perfusion, stabilizing the client. Notification, labs, and documentation follow stabilization.
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Following change-of-shift report on an orthopedic unit, which client should the nurse see first?
- A. 16 year-old who had an open reduction of a fractured wrist 10 hours ago
- B. 20 year-old in skeletal traction for 2 weeks since a motor cycle accident
- C. 72 year-old recovering from surgery after a hip replacement 2 hours ago
- D. 75 year-old who is in skin traction prior to planned hip pinning surgery.
Correct Answer: C
Rationale: Look for the client who has the most imminent risks and acute vulnerability. The client who returned from surgery 2 hours ago is at risk for life threatening hemorrhage and should be seen first.
The clinic nurse has contributed to the teaching plan for the following 6 clients. The nurse reinforces the teaching by instructing which client to avoid the Valsalva maneuver when defecating? Select all that apply.
- A. 22-year-old man with a head injury sustained during a college football game
- B. 30-year-old woman recently hospitalized for reconstructive augmentation mammoplasty
- C. 56-year-old man 2 weeks post myocardial infarction
- D. 68-year-old woman recently diagnosed with pancreatic cancer
- E. 74-year-old man with portal hypertension related to alcohol-induced cirrhosis
- F. 82-year-old woman 1 week post cataract surgery
Correct Answer: A,C,E,F
Rationale: The Valsalva maneuver increases intracranial pressure (head injury), cardiac strain (post-MI), intra-abdominal pressure (portal hypertension), and intraocular pressure (post-cataract surgery), risking complications. Mammoplasty and pancreatic cancer have less direct risks.
The nurse is caring for a client with partial hearing loss. Which of the following actions will promote effective communication? Select all that apply.
- A. Dim lights to prevent overstimulation
- B. Directly face the client when speaking
- C. Ensure hearing aids are properly applied
- D. Provide written information to supplement conversation
- E. Raise voice to speak loudly to the client
Correct Answer: B,C,D
Rationale: Facing the client aids lip-reading, properly applied hearing aids optimize hearing, and written information reinforces verbal communication. Dimming lights may hinder lip-reading, and shouting distorts speech.
The nurse is caring for a client with latent pulmonary tuberculosis who has been receiving isoniazid daily for the past 2 months. The client reports numbness and tingling in the hands and feet. The nurse should recognize that the client is likely experiencing a deficiency in
- A. iron
- B. vitamin B6
- C. folic acid
- D. vitamin D3
Correct Answer: B
Rationale: Isoniazid can deplete vitamin B6 (pyridoxine), causing peripheral neuropathy (numbness, tingling). Other deficiencies (iron, folic acid, vitamin D3) don't typically cause neuropathy.
The nurse is caring for a client who will not use the train for transportation due to the fear of being trapped and unable to escape. The nurse should recognize that the client is likely experiencing
- A. generalized anxiety disorder
- B. social anxiety disorder
- C. agoraphobia
- D. acrophobia
Correct Answer: C
Rationale: Fear of being trapped in situations (e.g., trains) with no escape is characteristic of agoraphobia. Generalized anxiety involves broad worries, social anxiety focuses on social scrutiny, and acrophobia is fear of heights.