Nokea
All of the following clients need care. Who should the nurse see first?
- A. A diabetic whose blood sugar is 40
- B. A postoperative client who is complaining of severe pain
- C. A person with terminal cancer who is complaining of pain
- D. A client with an indwelling catheter who is complaining of bladder pain
Correct Answer: A
Rationale: A blood sugar of 40 indicates severe hypoglycemia, a life-threatening emergency requiring immediate intervention. Pain complaints are less urgent.
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Which laboratory test conducted on the client with diabetes mellitus indicates compliance?
- A. Fasting blood glucose
- B. Two-hour post-prandial
- C. Hgb A-1C
- D. Dextrostix
Correct Answer: C
Rationale: Hgb A-1C reflects average blood glucose over 2-3 months, indicating long-term compliance. Options A, B, and D provide short-term snapshots and are less reliable for compliance.
The nurse assesses the development of a three-month-old boy in the well-baby clinic.
- A. Which behavior in a three-month-old boy would be unexpected?
- B. The boy holds his head erect when sitting on the examination table.
- C. The boy tries to grasp a toy just out of reach.
- D. The boy turns his head to try to locate a sound.
- E. The boy smiles spontaneously when he sees his mother.
Correct Answer: B
Rationale: Grasping for objects out of reach is unexpected until around 6 months of age. Holding the head erect, turning toward sounds, and spontaneous smiling are developmentally appropriate for a three-month-old.
The nurse is caring for a client who is postoperative day 1 after a total hysterectomy. Which of the following findings should the nurse report immediately?
- A. Mild pain at the incision site.
- B. Temperature of 100.8°F (38.2°C).
- C. Scant vaginal bleeding.
- D. Urine output of 50 mL/hour.
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-hysterectomy complication. Options A, C, and D are normal.
A baby boy is delivered after a rapid labor of three hours. What nursing action takes priority in the immediate newborn period?
- A. Suctioning with a bulb syringe
- B. Wrapping the baby in warm blankets
- C. Applying identification bracelets and taking footprints
- D. Assigning an APGAR score
Correct Answer: A
Rationale: Suctioning with a bulb syringe clears airways, ensuring respiratory patency, the priority in the immediate newborn period to prevent aspiration.
The nurse is caring for a client who has right-sided weakness and has been told to use a cane for walking. Which action by the client indicates that he can use a cane correctly?
- A. He holds the cane in his right hand and moves the cane with the right leg when walking.
- B. He moves the cane from hand to hand when walking.
- C. He carries the cane in his left hand and moves it at the same time he moves his right foot.
- D. He puts the cane forward and then moves the left foot forward followed by the right foot.
Correct Answer: C
Rationale: Holding the cane in the left (unaffected) hand and moving it with the right (weak) leg provides support, indicating correct use.