Nokea
At 10:00 A.M., the nurse discovers a 75-year-old woman who is hospitalized with congestive heart failure on the floor beside the bed. She has a bruise on her leg, but x-rays reveal no fractures. How should the nurse record the incident in the client's chart?
- A. Client fell out of bed at 10 A.M. Physician notified. Incident report completed.'
- B. Client found on floor beside bed at 10 A.M. Alert and oriented times 3. States she slipped as she was standing up. Bruise (3 inches by 2 inches) on left hip. Denies pain. Dr. examined client. X-rays taken.'
- C. Client fell while getting out of bed. Seems okay. Charge nurse examined client. Doctor notified and incident report filed.'
- D. Found client on floor beside bed. Responds to questions. Red area on left hip. Notified charge nurse and physician.'
Correct Answer: B
Rationale: Accurate documentation includes specific details: time, client status, mechanism of fall, assessment findings (bruise size, orientation), and actions taken (physician notification, x-rays). This option is thorough and objective, unlike the others, which are vague or incomplete.
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An adult who has COPD is to start receiving oxygen at home. What teaching is essential for this client and his family?
- A. The client should wear synthetic clothes as much as possible.
- B. Oxygen flow should be 6 L/min.
- C. The wall-to-wall carpets should be covered with a cotton sheet where the client walks.
- D. If the client gets short of breath, the oxygen level should be increased 1 L at a time until breathing is easier.
Correct Answer: D
Rationale: Adjusting oxygen flow incrementally for shortness of breath ensures safety, as fixed 6 L/min may be excessive, synthetic clothes increase static risk, and carpet covering is unnecessary.
A 23-year-old man with Addison's disease comes to the health clinic. The nurse should expect the client to report that his skin has become
- A. darker and more pigmented.
- B. ruddy and oily.
- C. puffy and scaly.
- D. pale and dry.
Correct Answer: A
Rationale: increase in melanocyte-stimulating hormone results in 'eternal tan'
A client is scheduled for electromyography (EMG).
What should the nurse tell the client about the procedure?
- A. Your hair will be carefully washed prior to the procedure.'
- B. This is a noninvasive procedure that takes about 30 minutes.'
- C. A sedative will be given to you shortly before the procedure.'
- D. You will not be allowed to eat 4-6 hours before the procedure.'
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) usually performed on the legs (2) correct-electrodes are attached to legs, length of time for impulse transmission is measured (3) may impair Test results (4) doesn't involve general anesthesia or GI system
The nurse is caring for a client who is receiving IV vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood pressure of 130/80 mmHg.
- B. Heart rate of 88 bpm.
- C. Redness at the IV site.
- D. Urine output of 50 mL/hour.
Correct Answer: C
Rationale: Redness at the IV site suggests phlebitis or infiltration, which can lead to tissue damage or reduced vancomycin delivery, requiring immediate action. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 88 bpm, and urine output 50 mL/hour indicate stability.
The nurse is caring for a client who is receiving IV gentamicin for a gram-negative infection. Which of the following findings would be of GREATest concern to the nurse?
- A. Creatinine 2.0 mg/dL.
- B. Heart rate of 80 bpm.
- C. Blood pressure of 120/80 mmHg.
- D. Temperature of 99.5°F (37.5°C).
Correct Answer: A
Rationale: A creatinine of 2.0 mg/dL indicates renal impairment, a serious complication of gentamicin due to nephrotoxicity, requiring immediate evaluation. Options B, C, and D are normal or less concerning: heart rate 80 bpm, blood pressure 120/80 mmHg, and temperature 99.5°F are stable.