Nokea
An adult is admitted through the outpatient department for elective surgery today. The client is coughing and sneezing and has a temperature of 100.6°F. What should the nurse do next?
- A. Prepare the client for surgery as scheduled
- B. Explain to the client that a cold increases risks during surgery and ask if he/she is willing to assume those risks
- C. Call the physician before continuing preparations for surgery
- D. Ask what type of anesthesia the client is receiving
Correct Answer: C
Rationale: Infection increases surgical risks; notifying the physician allows for evaluation and possible postponement.
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A client with stage-four Parkinson's disease.
In developing discharge plans with the family of the client with stage-four Parkinson's disease, it is MOST important for the nurse to include which of the following activities?
- A. Ambulate twice daily.
- B. ROM exercise to all extremities four times a day.
- C. Include activities such as knitting and putting puzzles together.
- D. Encourage and provide writing materials.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) client would be unable to ambulate (2) correct-in stage four Parkinson's disease, client is immobile (3) client cannot perform activities that require small-muscle dexterity (4) client cannot perform activities that require small-muscle dexterity
A 15-month old is admitted in sickle crisis. The parents ask why the child did not have any symptoms until now. What should be included in the nurse's response?
- A. The child was probably not exposed to it until recently.
- B. Antibodies from the mother are present for the first year of life.
- C. The symptoms do not manifest until the child is no longer breastfeeding.
- D. High fetal hemoglobin levels prevent symptoms for the first year of life.
Correct Answer: D
Rationale: High fetal hemoglobin (HbF) in infants inhibits sickling, delaying sickle cell anemia symptoms until HbF decreases around 6-12 months, replaced by adult hemoglobin.
A client with newly diagnosed diabetes mellitus.
Which of the following statements, if made by the client to the nurse, would indicate that further teaching is necessary?
- A. I should cut my toenails straight across.
- B. I should not go barefoot.
- C. I should inspect my feet once a week.
- D. I should bathe my feet daily in warm water.
Correct Answer: C
Rationale: Strategy: 'Further teaching' indicates an incorrect response. (1) prevents ingrown nails (2) prevents possible injury to feet (3) correct-should inspect feet daily for blisters, sores, ingrown nails, and cuts (4) proper care
The licensed practical nurse is assisting the RN with preparation for administering a transfusion of whole blood. Which action by the nurse predisposes the client to the development of hyperkalemia?
- A. Allowing the blood to warm to room temperature
- B. Administering blood that is 24 hours old
- C. Administering blood with an 18-gauge needle
- D. Filling the drip chamber below the level of the filter
Correct Answer: A
Rationale: Allowing blood to warm to room temperature can cause red blood cells to hemolyze, releasing potassium and increasing the risk of hyperkalemia.
The nurse is performing physical assessments on adolescents. What finding would the nurse anticipate concerning female growth spurts?
- A. They occur about 2 years earlier than for males.
- B. They begin about the same time for males.
- C. They begin just prior to the onset of puberty.
- D. They are characterized by an increase in height of 4 inches each year.
Correct Answer: A
Rationale: They occur about 2 years earlier than for males. Females experience a growth spurt about 2 years earlier than their male peers.