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In caring for an elderly client with a depressed affect, which of the following nursing actions would be MOST appropriate to help the client to complete activities of daily living?
- A. Medicate the client before the activities begin.
- B. Develop a written schedule of activities, allowing extra time.
- C. Assist the client with grooming activities so it doesn't take as long.
- D. Provide frequent forceful direction to keep the client focused.
Correct Answer: B
Rationale: written schedule with built-in extra time will allow client to understand what is expected and will allow him to participate at a slower pace
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The nurse performs a routine IV tubing change on a 55-year-old woman with a central line. Fifteen minutes later, the nurse reenters the patient's room to find her cyanotic, short of breath, and complaining of pain. Her vital signs are BP 84/62, pulse 112, respirations 18.
What is the FIRST action the nurse should take?
- A. Call the physician to report the patient's symptoms.
- B. Lower the head of the bed and place the patient on her left side.
- C. Place the patient in high Fowler's position.
- D. Start oxygen at 4 L/min via nasal cannula.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) second action, first should respond to potential problem of emboli (2) correct-air will rise to right atrium, minimizes chance of air bubbles entering cerebral circulation (3) never done with shock, trapped air could travel to pulmonary circulation (4) not first action
The home care nurse is performing an assessment of a client with pneumonia secondary to chronic pulmonary disease. Which of the following goals is MOST appropriate?
- A. Maintain and improve the quality of oxygenation.
- B. Improve the status of ventilation.
- C. Increase oxygenation of peripheral circulation.
- D. Correct the bicarbonate deficit.
Correct Answer: B
Rationale: to improve the quality of ventilation would refer to levels of carbon dioxide and oxygen
Which of the following assessments would be a priority when documenting the nursing history of a two-year-old child?
- A. The child's rituals and routines at home.
- B. The child's understanding of hospitalization.
- C. The child's ability to be separated from the parents.
- D. The parent's methods for dealing with the child's temper tantrums.
Correct Answer: A
Rationale: during a crisis such as hospitalization, children are able to establish a sense of security through consistency of the rituals and routines from home
The nurse is caring for a client with deep vein thrombosis (thrombophlebitis) of the left leg. Which of the following would be an appropriate nursing goal for this client?
- A. Decrease inflammatory response in the affected extremity and prevent embolus formation.
- B. Increase peripheral circulation and oxygenation of the affected extremity.
- C. Prepare the client and family for anticipated vascular surgery on the affected extremity.
- D. Prevent hypoxia associated with the development of a pulmonary embolus.
Correct Answer: A
Rationale: important to prevent the complication of pulmonary embolism in clients at high risk
The nurse observes the following patients in the emergency department (ED). The FIRST patient the nurse should see is the
- A. 34-year-old man with a distended abdomen and splenomegaly.
- B. 8-month-old infant with facial ecchymosis who is crying loudly.
- C. 12-year-old boy with a possible fractured ankle.
- D. 44-year-old woman with possible whiplash from an automobile accident.
Correct Answer: A
Rationale: possibility of internal bleeding, life-threatening situation