Nokea
Based on the information in the client's medical record, which of the following findings require immediate follow-up? Select the 4 findings that require follow-up.
- A. Smoking marijuana to clear their mind
- B. Attends school regularly
- C. Heart rate 99/min
- D. Client experiences nightmares
- E. BP 122/80 mm Hg
- F. Caregiver reporting client acting differently than usual
- G. Witnessing their family's death
Correct Answer: A,D,F,G
Rationale: These findings suggest unresolved trauma and substance use, requiring intervention.
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A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?
- A. Temperature 37.4° C(99,3° F)
- B. Early decelerations in the FHR
- C. FHR baseline 170/min
- D. Contractions lasting 80 seconds
Correct Answer: C
Rationale: The correct answer is C: FHR baseline 170/min. A baseline fetal heart rate (FHR) of 170/min is considered tachycardia and may indicate fetal distress. The nurse should report this finding to the provider for further evaluation and intervention. Early decelerations in fetal heart rate (choice B) are generally considered normal and do not require immediate reporting. A slightly elevated temperature (choice A) may not be concerning during labor. Contractions lasting 80 seconds (choice D) can be normal in active labor.
While performing a routine assessment, a nurse notices fraying on the electrical cord of a client's continuous passive motion(CPM) device. Which of the following actions should the nurse take first?
- A. Initiate a requisition for a replacement CPM device.
- B. Report the defect to the equipment maintenance staff.
- C. Remove the device from the room.
- D. Ensure the device inspection sticker is current.
Correct Answer: C
Rationale: The correct answer is C: Remove the device from the room. The fraying electrical cord poses a serious safety hazard, risking electrical shock or fire. The first step is to remove the device to prevent harm to the client or others. Initiating a requisition (A) or reporting to maintenance staff (B) can follow, but immediate removal is crucial. Ensuring the inspection sticker is current (D) is not the priority when there is a safety issue.
A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr. Which of the following interventions should the nurse anticipate?
- A. Initiate continuous bladder irrigation.
- B. Administer a fluid bolus
- C. Clamp the catheter tubing for 30 min.
- D. Obtain a urine specimen for culture and sensitive
Correct Answer: B
Rationale: The correct answer is B: Administer a fluid bolus. The dark yellow urine output at 25 mL/hr indicates concentrated urine and potential dehydration. Administering a fluid bolus would help improve hydration status and increase urine output. Continuous bladder irrigation (A) is not indicated as there is no indication of bladder obstruction. Clamping the catheter tubing (C) can lead to urinary retention and should not be done without a specific reason. Obtaining a urine specimen for culture (D) is important, but addressing the dehydration issue takes priority.
A nurse is teaching a client who has a new diagnosis of diabetes mellitus about foot care. Which of the following instructions should the nurse include in the teaching?
- A. Soak feet twice daily.
- B. Round the edges of toenails when trimming
- C. Use moisturizing lotion between the toes.
- D. Wear clean cotton socks every day.
Correct Answer: D
Rationale: The correct answer is D: Wear clean cotton socks every day. This instruction is crucial for diabetic foot care as it helps prevent moisture buildup, reduces the risk of infections, and maintains proper foot hygiene. Clean cotton socks minimize friction, provide cushioning, and promote good circulation.
Rationale for other choices:
A: Soaking feet twice daily can lead to dry skin, increasing the risk of skin breakdown and infection.
B: Rounding the edges of toenails can cause injury and increase the risk of ingrown toenails.
C: Using moisturizing lotion between the toes can create a moist environment, promoting fungal growth and skin maceration.
Which of the following statements should the nurse make?
- A. Do you need a prescription for an antianxiety medication?
- B. Do you need information on hospice care?
- C. Would you like to talk to a counselor about advance directives?
- D. Would you like to speak to a spiritual advisor?
Correct Answer: D
Rationale: Spiritual support can help address emotional and existential concerns in terminally ill clients.