Nokea
All of the following clients are in need of an emergency assessment except:
- A. a bleeding client who has an injury from falling debris.
- B. an unresponsive client.
- C. a client with an old injury.
- D. a pregnant woman with imminent delivery.
Correct Answer: C
Rationale: The client with an old injury does not need an emergency assessment because this is not a life-threatening or new situation or condition.
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Which of these clients is the priority for the nurse to report to the public health department within the next 24 hours?
- A. An infant with a positive culture of stool for Shigella
- B. An elderly factory worker with a lab report that is positive for acid-fast bacillus smear
- C. A young adult commercial pilot with a positive histopathological examination from an induced sputum for Pneumocystis carinii
- D. A middle-aged nurse with a history of varicella zoster virus and with crops of vesicles on an erythematous base that appear on the skin
Correct Answer: B
Rationale: Tuberculosis is a reportable disease because persons who had contact with the client must be traced and often must be treated with chemoprophylaxis for a designated time.
A mother that has never breast-fed a child before is having trouble getting the baby to latch on to the breast. The baby has lost 3% of its birth weight within the first 2 days of life. The best statement is:
- A. The baby will eventually take to the breast.
- B. I can fix up a bottle if you want to try that.
- C. A small amount of weight loss in the first few days is normal.
- D. I can get the charge nurse to come and talk to you about breast-feeding.
Correct Answer: C
Rationale: 5-10% of birth weight loss following birth is normal for the first few days of life, and this response reassures the mother while allowing further discussion about breastfeeding challenges.
A nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse? A client with
- A. a Dopamine drip IV with vital signs monitored every 5 minutes
- B. a myocardial infarction that is free from pain and dysrhythmias
- C. a tracheotomy of 24 hours in some respiratory distress
- D. a pacemaker inserted this morning with intermittent capture
Correct Answer: B
Rationale: This client is the most stable with minimal risk of complications or instability. The nurse can utilize basic nursing skills to care for this client, making it suitable for a nurse from another unit.
Which of these clients would be the highest priority for the nurse to assign to a private room?
- A. A client with a new diagnosis of tuberculosis
- B. A client with a urinary tract infection
- C. A client post-appendectomy with a surgical site infection
- D. A client with seasonal influenza
Correct Answer: A
Rationale: A client with tuberculosis requires a private room with negative pressure to prevent airborne transmission of the disease.
The client had a THR. The nurse is discussing home modifications with the client's son. Which modifications should the nurse recommend? Select all that apply.
- A. Pad bed side rails.
- B. Install safety bars around the toilet and shower.
- C. Install an elevated toilet seat in the bathroom.
- D. Plan for the client's bed to be in a main floor room.
- E. Use a nonskid bathmat in the bathtub for the client's daily bath.
- F. Remove scatter rugs and secure electrical cords against baseboards.
Correct Answer: B,C,D,F
Rationale: B: Safety bars aid mobility. C: Elevated toilet seat prevents excessive hip flexion. D: Main floor bedroom avoids stairs. F: Removing rugs and cords prevents tripping. A is unnecessary, and E is incorrect as tub baths are avoided post-THR.