Nokea
How would you respond to a family member experiencing anticipatory grieving who emotionally withdraws from the client?
- A. Encourage continued engagement and communication.
- B. Allow space while offering support and reassurance.
- C. Advise them to focus solely on practical matters.
- D. Recommend avoiding the client until after their passing.
Correct Answer: B
Rationale: Offering support while respecting emotional withdrawal helps family members process grief at their own pace.
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Which of the following nursing actions is helpful for older clients who are experiencing lens changes associated with aging?
- A. Offering teaching aids with large-sized letters
- B. Suggesting reduced visual activity such as reading or watching television
- C. Suggesting the use of eye drops for comfort
- D. Suggesting the use of glasses or contact lenses
Correct Answer: A
Rationale: Large-sized letters help compensate for decreased visual acuity due to aging-related lens changes.
While suctioning the endotracheal tube of a client on a ventilator, the nurse notices an increase in the client's heart rate from 86/min to 110/min, with irregularity. What should the nurse do next?
- A. Obtain a cardiology consult.
- B. Suction the client less frequently.
- C. Administer an antidysrhythmic medication.
- D. Perform pre-oxygenation prior to suctioning.
Correct Answer: D
Rationale: The correct answer is D: Perform pre-oxygenation prior to suctioning. In this scenario, the increase in heart rate and irregularity could be due to hypoxia resulting from suctioning. Pre-oxygenation helps to ensure adequate oxygenation before the procedure, preventing hypoxia-induced dysrhythmias. By providing oxygen before suctioning, the nurse can minimize the risk of further complications.
Choice A (Obtain a cardiology consult) is incorrect because immediate action is required to address the potential hypoxia, which can be managed by pre-oxygenation.
Choice B (Suction the client less frequently) is incorrect as it does not address the immediate concern of potential hypoxia leading to dysrhythmias.
Choice C (Administer an antidysrhythmic medication) is incorrect as it is not the initial intervention needed in this situation; addressing the underlying cause of potential hypoxia is essential before considering antidysrhythmic medications.
Priority Decision: A patient in the PACU has emergence delirium manifested by agitation and thrashing. What should the nurse assess for first in the patient?
- A. Hypoxemia
- B. Neurologic injury
- C. Distended bladder
- D. Cardiac dysrhythmias
Correct Answer: A
Rationale: Hypoxemia is a common cause of agitation and delirium during emergence from anesthesia.
Bob is diagnosed with idiopathic thrombocytopenic purpura (ITP). You realize that he has an increased risk of bleeding and you must monitor
- A. WBC and bleeding time.
- B. Prothrombin time (PT) and partial thromboplastin time (PTT).
- C. Platelet count and RBC.
- D. Iron and ferritin levels.
Correct Answer: C
Rationale: Low platelet count increases the risk of bleeding in ITP.
The old-old population (85 years and older) has an increased risk for frailty. However, old age is just one element of frailty. Identify at least three other assessment findings that contribute to frailty.
- A. Decreased muscle mass
- B. Weight loss
- C. Reduced physical activity
- D. Increasing disability and symptoms
Correct Answer: A
Rationale: Decreased muscle mass, unintentional weight loss, and reduced physical activity are key contributors to frailty in older adults.