Nokea
An 85-year-old woman recovering from a fractured pelvis in a long-term care facility. The woman's activity order reads: ambulate with walker bid.
After the nurse implements the order, which of the following charting entries is BEST?
- A. Patient ambulated well with walker. States has no c/o stiffness or pain. Did not appear fatigued.'
- B. Ambulated without difficulty for 20 minutes. Vital signs remained stable. Color good.'
- C. Walked full length of hall with walker. No difficulty with balance. Using walker correctly.'
- D. Patient ambulated 60 feet independently with walker. Gait steady. Respirations 14 and unlabored.'
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) gives subjective information (2) gives judgments without objective information (3) information is not complete, contains some judgments without objective information (4) correct-gives objective information
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A 68-year-old client has an order for hydrochlorothiazide (Hydrodiuril) 50 mg qd. The nurse knows that teaching has been successful if the client makes which of the following statements?
- A. I should not operate heavy machinery.
- B. I should drink only five glasses of liquid per day.
- C. This medication will cause my urine to turn orange.
- D. I should eat dried apricots each day.
Correct Answer: D
Rationale: Hydrochlorothiazide causes potassium loss; eating potassium-rich apricots indicates understanding. Options A, B, and C are incorrect.
A newborn is to be discharged in the AM.
The nurse should teach the child's mother to perform which of the following actions?
- A. Apply a sterile gauze dressing with petroleum jelly to the cord.
- B. Position the diaper over the umbilicus to keep it dry.
- C. Clean the cord several times a day and expose it to air frequently.
- D. Apply erythromycin ointment to the cord several times a day.
Correct Answer: C
Rationale: Strategy: The topic of the question is unstated. (1) appropriate for circumcision (2) will keep the area moist; the diaper should be placed below the umbilicus (3) correct-encourages drying and helps to prevent infection (4) antibiotic ointment is unnecessary
The nurse is performing a physical assessment on a client with insulin dependent diabetes mellitus. Which client finding calls for immediate nursing action?
- A. Diaphoresis and shakiness
- B. Reduced lower leg sensation
- C. Intense thirst and hunger
- D. Painful hematoma on thigh
Correct Answer: A
Rationale: Diaphoresis and shakiness. Diaphoresis is a sign of hypoglycemia, which warrants immediate attention to prevent severe complications.
The physician's orders include warm compresses to the left leg three times a day for treatment of an open wound. Which action is appropriate when carrying out these orders?
- A. Use medical aseptic technique.
- B. Leave the wet compress open to the air.
- C. Place both a dry covering and waterproof material over the compress.
- D. Remove the compress after five minutes.
Correct Answer: C
Rationale: A dry covering and waterproof material over the compress maintain warmth and prevent contamination while keeping the surrounding area dry. Aseptic technique is needed for open wounds, open-air compresses lose heat, and five minutes is too short.
The nurse should visit which of the following clients first?
- A. The client with diabetes with a blood glucose of $95 \mathrm{mg} / \mathrm{dL}$
- B. The client with hypertension being maintained on Lisinopril
- C. The client with chest pain and a history of angina
- D. The client with Raynaud's disease
Correct Answer: C
Rationale: Chest pain in a client with a history of angina suggests possible acute coronary syndrome, requiring immediate assessment to rule out myocardial infarction.