Nokea
An RN who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN?
- A. A middle-aged client who says 'I took too many diet pills' and 'my heart feels like it is racing out of my chest.'
- B. A young adult who says 'I hear songs from heaven. I need money for beer. I quit drinking 2 days ago for my family. Why are my arms and legs jerking?'
- C. An adolescent who was recently diagnosed with leukemia and started chemotherapy with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10
- D. An elderly client who reports having taken a 'large crack hit' 10 minutes prior to walking into the emergency room
Correct Answer: C
Rationale: Nurses who are floated to other units should be assigned to a client who has minimal anticipated immediate complications of their problem. The client in option C exhibits opioid toxicity with the pinpoint pupils and has the least risk of complications occurring in the near future.
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The nurse is caring for a client who had a portable water seal chest drainage system inserted today. Which observation indicates that the client's drainage system is working properly?
- A. There are no bubbles in the water seal bottle.
- B. The suction control chamber has continuous bubbles.
- C. There are bubbles in the drainage chamber.
- D. There is no fluctuation in the fluid in the water seal chamber.
Correct Answer: A
Rationale: No bubbles in the water seal bottle indicates a stable system without air leaks, confirming proper function post-insertion.
A client with acquired immunodeficiency syndrome is admitted for treatment of wasting syndrome. Which of the following dietary modifications can be used to compensate for the limited absorptive capability of the intestinal tract?
- A. Thoroughly cooking all foods
- B. Offering yogurt and buttermilk between meals
- C. Forcing fluids
- D. Providing small, frequent meals
Correct Answer: D
Rationale: Small, frequent meals are easier to digest and absorb, compensating for the limited absorptive capacity in wasting syndrome. Cooking foods thoroughly reduces infection risk but doesn't aid absorption. Yogurt and buttermilk may not be tolerated, and forcing fluids addresses hydration, not absorption.
The practical nurse is performing a physical examination with the registered nurse on a 2-year-old with cold symptoms and a fever at home of 101.7 F (38.7 C). Which interventions will enhance the child's cooperation during the examination? Select all that apply.
- A. Allow the child to play with the stethoscope
- B. Begin with the child in the parent's lap
- C. Interact with the parent in a friendly manner
- D. Play with the child using a finger puppet
- E. Start by taking the child's vital signs
Correct Answer: A,B,C,D
Rationale: Playing with the stethoscope (A), starting in the parent's lap (B), friendly interaction (C), and using a puppet (D) reduce anxiety and enhance cooperation. Vital signs (E) may distress the child if done first.
The nurse is caring for a client with a tracheostomy who has an order to begin oral intake. Which of the following actions should the nurse take to decrease the client's risk for aspiration?
- A. Fully inflate the tracheostomy cuff before the client begins to eat.
- B. Encourage the client to use a straw when drinking fluids.
- C. Instruct the client to tilt the head back when swallowing
- D. Provide thickened liquids for the client.
Correct Answer: D
Rationale: Thickened liquids (D) reduce aspiration risk by slowing transit. Inflating the cuff (A) is not always necessary, straws (B) may increase risk, and tilting the head back (C) worsens aspiration.
An adult is prescribed sulfisoxazole (Gantrisin) for a urinary tract infection. Which comment by the client indicates understanding of the treatment regimen?
- A. When I feel better, I can stop taking the medicine.
- B. I will stay out of the sun when I am taking this drug.
- C. I should restrict fluids during the evening as long as I am on the medicine.
- D. I will bring in a urine specimen every day while I am taking the drug.
Correct Answer: B
Rationale: Sulfisoxazole causes photosensitivity; avoiding sun exposure is critical to prevent skin reactions, indicating understanding.