Nokea
Nurse reviews the assessment findings. Which findings require immediate follow-up?
- A. Right forearm and fingers are edematous.
- B. Ecchymotic area noted on outer aspect of the forearm.
- C. Heart rate 102/min
- D. Fingers slightly cool to touch.
- E. Child verbalizes a pain level of 4 on a scale of 0 to 10
- F. Respiratory rate 22/min
Correct Answer: A,D
Rationale: Edema and coolness in the extremity suggest circulatory impairment, warranting immediate attention.
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Which of the following actions should the nurse take?
- A. Maintain the irrigation solution rate.
- B. Increase the irrigation solution rate.
- C. Clamp the catheter for 30 minutes and reassess.
- D. Notify the provider immediately.
Correct Answer: A
Rationale: The correct answer is A: Maintain the irrigation solution rate. This is the appropriate action because maintaining the irrigation solution rate ensures continuous flushing of the catheter to prevent blockages and maintain patency. Increasing the rate could lead to complications like fluid overload. Clamping the catheter and reassessing can cause catheter obstruction. Notifying the provider immediately may not be necessary unless there are specific complications or concerns.
Which statement should the nurse make?
- A. Your desire to be an organ donor must be documented in writing
- B. You have the right to change your decision about organ donation at any time.
- C. Discussing your wishes with your family can help ensure they are honored.
- D. Organ donation does not delay funeral arrangements or affect body appearance.
- E. Medical care provided before death will not be affected by your organ donor status.
Correct Answer: E
Rationale: The correct answer is E because it addresses a common misconception. Organ donor status does not affect medical care provided before death. Choice A is incorrect as organ donor consent can also be verbal. Choice B is incorrect because changing one's decision about organ donation may not always be feasible in emergency situations. Choice C is incorrect as discussing wishes with family does not guarantee they will be honored legally. Choice D is incorrect as organ donation may have some impact on funeral arrangements and body appearance.
Which action should the nurse include in the plan?
- A. Offer the client three large meals each day
- B. Provide small, frequent meals to reduce fatigue and improve intake.
- C. Encourage the client to drink fluids immediately before or after meals to prevent early satiety.
- D. Offer high-calorie, nutrient-dense foods to support weight maintenance.
- E. Monitor the client's weight regularly to assess nutritional status.
Correct Answer: B
Rationale: The correct answer is B: Provide small, frequent meals to reduce fatigue and improve intake. This option is the most appropriate because small, frequent meals can help prevent fatigue and improve nutrient intake by ensuring a steady supply of energy throughout the day. Offering three large meals (option A) may overwhelm the client and lead to fatigue. Encouraging fluid intake before or after meals (option C) may cause early satiety and reduce food intake. Offering high-calorie, nutrient-dense foods (option D) can be beneficial, but the frequency of meals is more crucial in this scenario. Monitoring weight (option E) is important but does not directly address the issue of fatigue and intake.
Which of the following statements should the nurse include in the client's teaching?
- A. Take hot showers to help relieve itching
- B. Wear flat or low-heeled shoes
- C. You can douche twice weekly
- D. Wear loose-fitting clothing
- E. Try using an abdominal support belt
- F. You should avoid fried foods
- G. Eat two large meals a day
Correct Answer: B,D,F
Rationale: Wearing flat shoes, wearing loose-fitting clothes, and avoiding fried foods are beneficial practices during pregnancy.
Which action should the nurse take to address suspicion of elder abuse?
- A. Privately interview the client about the injuries
- B. Document the injuries in detail, including size, location, and appearance
- C. Report the findings to the appropriate authorities, following facility protocol
- D. Take photographs of the injuries if permitted, as part of the documentation process
- E. Ensure that the client is not left alone with the suspected abuser during the interview or assessment
Correct Answer: C
Rationale: The correct action for the nurse to address suspicion of elder abuse is to report the findings to the appropriate authorities, following facility protocol (Choice C). This is because reporting to the authorities is crucial to protect the elderly individual from further harm and ensure that the necessary interventions are implemented.
- Choice A: Privately interviewing the client may jeopardize the safety of the elderly individual and may not be the most effective immediate action.
- Choice B: Documenting the injuries is important but reporting to authorities takes precedence in cases of suspected elder abuse.
- Choice D: Taking photographs of the injuries may be helpful for documentation but should not delay reporting to authorities.
- Choice E: Ensuring the client is not left alone with the suspected abuser is important but is not as urgent as reporting the abuse to the authorities.
In conclusion, reporting the findings to the appropriate authorities is the most critical and immediate action to address suspicion of elder abuse.