Nokea
A preschool client's mother reports that the child has frequent bouts of gastroenteritis.
It would be MOST important for the nurse to ask which of the following questions?
- A. Are there other children in the family?'
- B. Does the child attend a day care center?'
- C. Does the child play with neighborhood children?'
- D. Is the child current on his immunizations?'
Correct Answer: B
Rationale: Strategy: Determine why the nurse would make the assessment and how it relates to gastroenteritis. (1) does not pose a problem or solution regarding gastroenteritis (2) correct-environments with increased numbers of children (day care) more likely to promote infections due to close living conditions and increased likelihood of disease transmission (3) possible source of infection, but not as likely as a day care center (4) does not pose a problem or solution regarding gastroenteritis
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A teenaged client states that she drinks 'lots' of fluids and still feels thirsty.
It is MOST important for the nurse to ask which of the following questions?
- A. Has your weight recently changed?'
- B. What medications do you take?'
- C. Do you have any allergies to food or medication?'
- D. How often do you menstruate?'
Correct Answer: A
Rationale: Strategy: Determine how each answer choice relates to the symptoms. (1) correct-excessive thirst and weight loss are two notable symptoms of diabetes mellitus (IDDM) (2) does not provide useful information related to the assessment information (3) does not provide useful information related to the assessment information (4) does not provide useful information related to the assessment information
A client with asthma has low pitched wheezes present on the final half of exhalation. One hour later the client has high pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client
- A. Has increased airway obstruction
- B. Has improved airway obstruction
- C. Needs to be suctioned
- D. Exhibits hyperventilation
Correct Answer: A
Rationale: Has increased airway obstruction. The higher pitched a sound is, the more narrow the airway. Therefore, the obstruction has increased or worsened.
A client receiving Eskalith (lithium carbonate) has a level of 4.5 mEq/L. The nurse should prepare the client for immediate:
- A. Blood transfusion
- B. Hemodialysis
- C. Renal biopsy
- D. Brain scan
Correct Answer: B
Rationale: A lithium level of 4.5 mEq/L indicates severe toxicity, requiring hemodialysis to rapidly remove lithium from the body.
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.
A nurse has asked a second staff nurse to sign for a wasted narcotic, which was not witnessed by another person. This seems to be a recent pattern of behavior. What is the appropriate initial action?
- A. Report this immediately to the nurse manager
- B. Confront the nurse about the suspected drug use
- C. Sign the narcotic sheet and document the event in an incident report
- D. Counsel the colleague about the risky behaviors
Correct Answer: A
Rationale: The incident must be reported to the appropriate supervisor, for both ethical and legal reasons. This is not an incident that a co-worker can resolve without referral to a manager.