Nokea
Select the 5 findings the nurse should plan to include in the report.
- A. Client's report of lack of food in home
- B. ECG results
- C. Numerous bruises in various stages of healing
- D. Client's avoidance of eye contact
- E. Client's report of lack of access to bank accounts
- F. Client’s report of weight loss
Correct Answer: A,C,D,E,F
Rationale: These findings highlight potential abuse and neglect indicators.
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Which of the following findings should the nurse report to the provider?
- A. Pink-tinged coloration on the incisional line
- B. Mild swelling under the sutures near the incisional line
- C. Crusting of exudate on the incisional line
- D. Partial separation of the upper part of the incisional line
Correct Answer: D
Rationale: Partial wound separation indicates potential complications needing attention.
A nurse is caring for a client who is in a coma and is scheduled for a surgical procedure. Which of the following actions should the nurse take?
- A. Send the unsigned informed consent form to the facility's risk manager.
- B. Determine if the client's health care surrogate is aware of the risks and benefits of the procedure.
- C. Ensure that the client's family supports the provider's decision for surgery,
- D. Determine if the procedure is medically necessary for the client.
Correct Answer: B
Rationale: The correct answer is B: Determine if the client's health care surrogate is aware of the risks and benefits of the procedure. This is important because the client is in a coma and unable to provide informed consent. The health care surrogate acts on behalf of the client and must be fully informed about the procedure to make decisions in the client's best interest. Sending the unsigned consent form to the risk manager (A) is not appropriate as it does not address the issue of informed consent. Ensuring family support (C) is important but does not address the legal requirement of informed consent. While determining medical necessity (D) is important, in this case, the primary concern is obtaining informed consent.
A nurse is reporting a client's laboratory tests to the provider to obtain a prescription for the cient's daily warfarin. Which of the following laboratory tests should the nurse plan to report to obtain the prescription for the warfarin?
- A. Fibrinogen level
- B. aPTT
- C. INR
- D. Platelet count
Correct Answer: C
Rationale: The correct answer is C: INR. The International Normalized Ratio (INR) is used to monitor and adjust the dosage of warfarin, an anticoagulant medication. A nurse needs to report the INR level to the provider to determine if the current dosage of warfarin is effective in preventing blood clots. A higher INR indicates a longer time it takes for blood to clot, meaning the warfarin dosage might need adjustment.
Incorrect choices:
A: Fibrinogen level - Fibrinogen is a protein involved in blood clotting but is not specific for monitoring warfarin therapy.
B: aPTT - Activated Partial Thromboplastin Time (aPTT) is used to monitor heparin therapy, not warfarin.
D: Platelet count - Platelet count measures the number of platelets in the blood and is not directly related to warfarin therapy.
Overall, the INR is the most
A nurse is teaching a client who has a new diagnosis of diabetes mellitus about foot care. Which of the following instructions should the nurse include in the teaching?
- A. Soak feet twice daily.
- B. Round the edges of toenails when trimming
- C. Use moisturizing lotion between the toes.
- D. Wear clean cotton socks every day.
Correct Answer: D
Rationale: The correct answer is D: Wear clean cotton socks every day. This instruction is crucial for diabetic foot care as it helps prevent moisture buildup, reduces the risk of infections, and maintains proper foot hygiene. Clean cotton socks minimize friction, provide cushioning, and promote good circulation.
Rationale for other choices:
A: Soaking feet twice daily can lead to dry skin, increasing the risk of skin breakdown and infection.
B: Rounding the edges of toenails can cause injury and increase the risk of ingrown toenails.
C: Using moisturizing lotion between the toes can create a moist environment, promoting fungal growth and skin maceration.
Which of the following findings should the nurse expect?
- A. The client is oriented times three
- B. The client opens eyes to sound.
- C. The client is unable to obey commands.
- D. The client withdraws from pain
Correct Answer: A
Rationale: The correct answer is A: The client is oriented times three. This indicates that the client is alert and aware of person, place, and time. This finding is crucial in assessing the client's mental status and cognitive function. Opening eyes to sound (B) is a basic response but does not indicate orientation. Inability to obey commands (C) suggests altered mental status. Withdrawing from pain (D) may indicate a physical reflex rather than cognitive function. Overall, being oriented times three is the most comprehensive assessment of mental alertness and cognitive function.