Nokea
Four clients arrive in the urgent care clinic. Which does the nurse anticipate to be the priority for intervention?
- A. Child who is confused and irritable and whose parent claims 2 glyburide pills are missing
- B. Child with an abscess on the buttock that is red, swollen, and warm to the touch
- C. Child with immune thrombocytopenia who fell off a bike and reports shoulder pain
- D. Child with low-grade fever, barking cough, and runny nose who has mild retractions
Correct Answer: A
Rationale: The child who is confused and irritable with missing glyburide pills suggests a potential hypoglycemic emergency due to sulfonylurea overdose, which requires immediate intervention to prevent severe complications like seizures or coma.
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The nurse manager hears a provider loudly criticize one of the staff nurses within the hearing range of others. The nurse manager's next action should be to
- A. Walk up to the provider and quietly state: 'Stop this unacceptable behavior.'
- B. Allow the staff nurse to handle this situation without interference
- C. Notify the chief of the other administrative persons of a breech of professional conduct
- D. Request an immediate private meeting with the provider and staff nurse
Correct Answer: D
Rationale: Assertive communication respects the needs of all parties to express themselves, but not at the expense of others. The nurse manager needs to protect clients and staff from this display and assist the nurse employee.
A client with metabolic acidosis associated with diabetes mellitus is admitted to the unit. A blood glucose of $250 \mathrm{mg} / \mathrm{dl}$ is present. Which symptom will most likely accompany ketoacidosis?
- A. Oliguria
- B. Polydipsia
- C. Perspiration
- D. Tremors
Correct Answer: B
Rationale: Diabetic ketoacidosis (DKA) causes dehydration due to hyperglycemia, leading to polydipsia (excessive thirst). Oliguria may occur later, perspiration is not specific, and tremors are more associated with hypoglycemia.
The nurse is caring for a client with a venous stasis ulcer. Which nursing intervention would be most effective in promoting healing?
- A. Apply dressing using sterile technique
- B. Improve the client's nutrition status
- C. Initiate limb elevation and compression
- D. Begin proteolytic debridement
Correct Answer: B
Rationale: The goal of clinical management in a client with venous stasis ulcers is to promote healing. This only can be accomplished with proper nutrition. The other interventions are appropriate, but without proper nutrition, they would be of little help.
The nurse is collecting data from a client who had a transurethral resection of the prostate 10 hours ago and is receiving continuous bladder irrigation. Which of the following findings would require follow-up?
- A. blood pressure of 114/70 mm Hg and heart rate of 66/min
- B. reports relief of bladder spasms after administration of oxybutynin
- C. light pink urine is noted in the catheter tubing and urinary drainage bag
- D. bladder irrigation input of 3000 mL and urine output of 2800 mL over the past 4 hours
Correct Answer: D
Rationale: A 200 mL discrepancy between irrigation input and output suggests possible catheter obstruction or absorption, requiring follow-up. Normal vitals , spasm relief , and light pink urine are expected post-TURP.
The nurse walks into a client's room and finds the client lying still and silent on the floor. The nurse should first
- A. Assess the client's airway
- B. Call for help
- C. Establish that the client is unresponsive
- D. See if anyone saw the client fall
Correct Answer: C
Rationale: Establish that the client is unresponsive. This is the first step in CPR to determine the need for further action.