Nokea
An elderly man is admitted to an inpatient psychiatric unit with an initial diagnosis of psychotic depression. The INITIAL nursing priority is to
- A. clarify perceptual distortions.
- B. establish reality orientation.
- C. ensure client and milieu safety.
- D. increase self-esteem.
Correct Answer: C
Rationale: initial nursing priority for all psychiatric patients is to ensure their safety and the safety of all members of the milieu
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A client has a bovine graft inserted into the left arm for hemodialysis. During the immediate postoperative period, which of the following actions, if performed by the nurse, is BEST?
- A. Restart the IV above the level of the graft.
- B. Take blood pressures only on the right arm.
- C. Elevate the left arm above the level of the heart.
- D. Check the radial pulse on the left arm q 4h.
Correct Answer: B
Rationale: BP should always be taken on the opposite arm from the graft
The nurse observes the following patients in the emergency department (ED). The FIRST patient the nurse should see is the
- A. 34-year-old man with a distended abdomen and splenomegaly.
- B. 8-month-old infant with facial ecchymosis who is crying loudly.
- C. 12-year-old boy with a possible fractured ankle.
- D. 44-year-old woman with possible whiplash from an automobile accident.
Correct Answer: A
Rationale: possibility of internal bleeding, life-threatening situation
The nurse has just received report from the previous shift. Which of the following clients should the nurse see FIRST?
- A. A client with chronic renal failure complaining of swollen fingers and ankle edema.
- B. A client one-day postoperative after abdominal surgery who has dried blood on the abdominal dressing.
- C. A client with type I diabetes mellitus who states, 'I have this quivering feeling in my abdomen.'
- D. A client on high doses of antibiotics for a resistant infection who complains of diarrhea.
Correct Answer: C
Rationale: indicates hypoglycemia; symptoms include tachycardia, cold and clammy skin, weakness and pallor; check blood sugar, offer milk
A five-year-old is scheduled for a lumbar puncture (LP). Which of the following nursing actions would BEST prepare the child for the procedure?
- A. Explain the procedure in detail.
- B. Show a video of the procedure.
- C. Do a mock run-through of the procedure.
- D. Answer all questions simply and honestly.
Correct Answer: C
Rationale: excellent method to use with a child because it incorporates actually 'feeling' many aspects of the procedure as they are explained
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen at 2 L/min via nasal cannula. The client reports increased shortness of breath. Which of the following actions should the nurse take FIRST?
- A. Increase the oxygen flow to 4 L/min.
- B. Check the client's oxygen saturation.
- C. Place the client in a supine position.
- D. Administer a bronchodilator as ordered.
Correct Answer: B
Rationale: checking oxygen saturation provides objective data to assess the client's respiratory status