Nokea
Nurse in clinic caring for 21-year-old client who reports sore throat. Client tells nurse he hasn't seen a doctor since high school. Which health screening should nurse expect provider to perform for this client?
- A. Testicular exam
- B. Blood glucose
- C. Fecal occult blood
- D. Prostate-specific antigen
Correct Answer: A
Rationale: The correct answer is A: Testicular exam. The provider should perform this screening for a 21-year-old male as part of routine health maintenance. Testicular cancer is most common in young males, and early detection through a testicular exam is crucial for successful treatment. Blood glucose (B) screening is typically done for diabetes risk assessment, which is less likely in a young, asymptomatic individual. Fecal occult blood (C) screening is for colorectal cancer, typically recommended for individuals over 50. Prostate-specific antigen (D) screening is for prostate cancer, which is rare in young males and not recommended without specific risk factors.
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Nurse on med-surg unit is informed that mass casualty event occurred & it's necessary to discharge clients to make beds available for injury victims. Which clients can be safely discharged? (Select all that apply.)
- A. Client who's dehydrated & receiving IV fluid/electrolytes
- B. Client with NG tube to treat small bowel obstruction
- C. Client who's scheduled for TURP (prostate resection)
- D. Client who is 24h post-op after mastectomy
- E. Client scheduled for appendectomy
Correct Answer: C,D
Rationale: The correct answers are C and D.
C: The client scheduled for a TURP (transurethral resection of the prostate) can be safely discharged as this surgery is elective and not urgent.
D: The client who is 24 hours post-op after a mastectomy can also be discharged as they are stable and beyond the immediate post-operative phase.
A: Client receiving IV fluids for dehydration should not be discharged as they require ongoing treatment and monitoring.
B: Client with an NG tube for a small bowel obstruction should not be discharged as they require close observation and treatment.
E: Client scheduled for an appendectomy should not be discharged as this procedure is likely urgent and may require immediate attention.
Nurse educator is reviewing with newly hired nurse the difference in clinical manifestations of localized vs. systemic infection. Nurse indicates understanding when she states that which are manifestations of systemic?
- A. Fever
- B. Malaise
- C. Edema
- D. Pain/tenderness
- E. Increase in pulse & respiratory rate
Correct Answer: A,B,E
Rationale: The correct answer is A, B, and E. Systemic infection manifests with fever, malaise, and an increase in pulse and respiratory rate. Fever is the body's response to infection, malaise is a general feeling of discomfort, and increased pulse and respiratory rate indicate the body's effort to fight infection. Edema and pain/tenderness are more indicative of localized infection rather than systemic. In summary, the correct manifestations of systemic infection are fever, malaise, and an increase in pulse and respiratory rate, while edema and pain/tenderness are more likely to be seen in localized infections.
Nurse educator is teaching module on proper body mechanics during employee orientation. Which statement by new nurse indicates need for more teaching?
- A. My line of gravity should fall outside my base of support
- B. The lower my center of gravity
- C. the more stability I have
- D. To broaden my base of support
- E. I should spread my feet apart
- F. I should hold it as close to my body as possible
Correct Answer: A
Rationale: Answer A is correct because the statement "My line of gravity should fall outside my base of support" indicates a misunderstanding of proper body mechanics. The line of gravity should fall within the base of support to maintain balance and prevent falls. Choices B, C, D, E, and F all reflect accurate understanding of body mechanics, emphasizing lowering the center of gravity, broadening the base of support, spreading feet apart for stability, and holding objects close to the body for leverage and control. Therefore, these choices do not indicate a need for more teaching.
Nurse collecting hx & physical exam data from middle adult. Nurse should expect to find decreases in which physiologic functions? (Select all that apply.)
- A. Metabolism
- B. Ability to hear low-pitched sounds
- C. Gastric secretion
- D. Far vision
- E. Glomerular filtration
Correct Answer: A,C,E
Rationale: The correct answers are A, C, and E. As individuals age, metabolism decreases due to changes in muscle mass and activity levels. Gastric secretion decreases, leading to decreased absorption of certain nutrients. Glomerular filtration rate decreases with age, affecting kidney function. Choice B is incorrect as hearing high-pitched sounds is more commonly affected with age. Choice D is incorrect as near vision is usually affected, not far vision.
A nurse manager of a med-surg unit is assigning care responsibilities for the oncoming shift. A client is awaiting transfer from PACU following thoracic surgery. To which staff member should the nurse assign this client?
- A. Charge nurse
- B. RN
- C. LPN
- D. Assistive personnel (AP)
Correct Answer: B
Rationale: The correct answer is B: RN. A registered nurse (RN) is the most appropriate staff member to care for a client awaiting transfer from PACU after thoracic surgery. RNs have the education and training to assess the client's condition, monitor vital signs, manage postoperative pain, and recognize any complications that may arise. They can also provide the necessary interventions and communicate effectively with the healthcare team. Assigning this client to an RN ensures safe and competent care.
Choice A (Charge nurse) may have administrative duties and may not be available to provide direct care. Choice C (LPN) may not have the scope of practice or training to manage postoperative care for a client following thoracic surgery. Choice D (AP) does not have the qualifications to assess and manage a client with complex postoperative needs.