Nokea
After receiving report, which of the following patients should the nurse see FIRST?
- A. A patient in sickle-cell crisis with an infiltrated IV.
- B. A patient with leukemia who has received one-half unit of packed cells.
- C. A patient scheduled for a bronchoscopy.
- D. A patient complaining of a leaky colostomy bag.
Correct Answer: A
Rationale: IV fluids are critical to reduce clotting and pain.
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While planning care for an elderly client with dementia, which of the following should be a priority for the nurse?
- A. Encourage dependency with activities of daily living.
- B. Provide flexibility in schedules due to his confusion.
- C. Limit reminiscing due to poor memory.
- D. Speak slowly in a face-to-face position.
Correct Answer: D
Rationale: is most effective when communicating with an elderly client
The nurse is teaching a client with chronic obstructive pulmonary disease (COPD) about home oxygen therapy. Which of the following instructions should the nurse include?
- A. Use oxygen only when feeling short of breath.
- B. Store oxygen tanks near an open flame.
- C. Avoid smoking while using oxygen.
- D. Use a humidifier with oxygen at high flow rates.
Correct Answer: C
Rationale: Smoking near oxygen risks fire, a critical safety concern. Options A, B, and D are incorrect or unsafe.
The nurse is caring for clients in the outpatient clinic. The nurse returns to the desk and finds four phone messages. Which of the following messages should the nurse return FIRST?
- A. A client with cold symptoms has an oral temperature of 103°F (39.4°C).
- B. A client with stage II decubitus ulcer reports that the dressing has come off.
- C. A client is nauseated and has vomited 6 times in the previous 24 hours.
- D. A client is complaining of leg pain after walking half a mile.
Correct Answer: C
Rationale: assess amount, character, symptoms of fluid volume deficit
A group of senior citizens.
The nurse teaches a health class at the local library to a group of senior citizens. Which of the following behaviors should the nurse emphasize to facilitate regular bowel elimination?
- A. Avoid strenuous activity.
- B. Eat more foods with increased bulk.
- C. Decrease fluid intake to decrease urinary losses.
- D. Use oral laxatives so that a bowel pattern emerges.
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) regular exercise program facilitates bowel elimination (2) correct-contained in whole grains, legumes, vegetables, fruits, seeds, nuts, bulk promotes peristalsis (3) normal fluid intake of 1,500 cc/day facilitates bowel elimination (4) laxatives used as last resort because they become habit-forming
A client comes to the clinic complaining of severe facial pain. In order to collect subjective data from the client, it is MOST important for the nurse to
- A. obtain the client's vital signs.
- B. interview the client.
- C. inspect the face for grimacing.
- D. administer pain medication.
Correct Answer: B
Rationale: subjective data is collected in the health history or interview