Nokea
All of the following are common symptoms seen in clients diagnosed with tuberculosis (TB) EXCEPT
- A. nail clubbing.
- B. night sweats.
- C. weight gain.
- D. fever.
Correct Answer: C
Rationale: TB symptoms include night sweats, fever, and weight loss. Weight gain is not typical, and nail clubbing is more associated with chronic lung conditions like COPD.
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The nurse is caring for a client admitted with chest pain and atrial fibrillation. The nurse accidentally gives the client the wrong dose of digoxin. The client is monitored throughout the shift and no ill effects are noted. Which actions by the nurse are correct? Select all that apply.
- A. fill out an incident report and make a note of it in the nurse's notes
- B. print out rhythm strips every 2 hours and place on the client's chart
- C. fill out an incident report and notify the health care provider for further orders
- D. notify the health care provider at the end of the shift, since no ill effects were observed
- E. notify the pharmacy that they loaded the wrong dose in the automatic medication dispensing system
Correct Answer: C
Rationale: Filling out an incident report and notifying the provider immediately are necessary to address the medication error and ensure client safety, even if no ill effects were observed.
The nurse is caring for an elderly female client in an extended care facility who has dry age-related macular degeneration (AMD). Which nursing intervention would be the most appropriate?
- A. provide written materials to explain medications
- B. stand in front of the client when addressing her
- C. limit room lighting to create a relaxed environment
- D. encourage use of radio and CDs
Correct Answer: B
Rationale: Standing in front of the client maximizes her ability to see the nurse, as dry AMD affects central vision, making clear visual communication essential.
The nurse is teaching a group of new graduates about the safety needs of the client receiving chemotherapy. Before administering chemotherapy, the nurse should:
- A. Administer a bolus of IV fluid
- B. Administer pain medication
- C. Administer an antiemetic
- D. Allow the patient a chance to eat
Correct Answer: C
Rationale: Administering an antiemetic before chemotherapy prevents nausea and vomiting, common side effects of these drugs.
A client with mania is unable to finish her dinner. To help her maintain sufficient nourishment, the nurse should:
- A. Serve high-calorie foods she can carry with her
- B. Encourage her appetite by sending out for her favorite foods
- C. Serve her small, attractively arranged portions
- D. Allow her in the unit kitchen for extra food whenever she pleases
Correct Answer: A
Rationale: High-calorie, portable foods accommodate the restlessness and distractibility of mania, ensuring adequate nutrition.
The clinic nurse is seeing a client who suffers from caregiver strain due to caring for her elderly parents who have dementia and live with her. Which action by the nurse during the assessment is most important?
- A. ask the client about her support systems
- B. ask the client what she does for relaxation
- C. ask if her parents' insurance covers adult day care for them
- D. offer to give her a list of nursing homes to care for her parents
Correct Answer: A
Rationale: Assessing support systems identifies resources to alleviate caregiver strain, guiding interventions to reduce stress.