Nokea
The charge nurse in a cardiac ICU is precepting a student nurse. Which action by the student nurse requires immediate intervention by the charge nurse?
- A. The student nurse stops the tube feeding to measure residual.
- B. The student nurse lifts the urinary catheter bag up and over the client while turning her.
- C. The student nurse scans the client armband and the medication barcode when administering medication.
- D. The student nurse observes two other nurses verifying and administering blood to the client while the student nurse records the vital signs just prior to administration.
Correct Answer: B
Rationale: Lifting the urinary catheter bag above the bladder risks backflow of urine, increasing infection risk, and requires immediate intervention.
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Which assessment finding in a client with COPD indicates to the nurse that the respiratory problem is chronic?
- A. Wheezing on exhalation
- B. Productive cough
- C. Clubbing of fingers
- D. Cyanosis
Correct Answer: C
Rationale: Clubbing of fingers is a sign of chronic hypoxia, indicative of long-standing COPD, unlike wheezing or cough, which can occur in acute or chronic stages.
The nurse caring for a client with a suspected peptic ulcer recognizes which exam as the one most reliable in diagnosing the disease?
- A. Upper-gastrointestinal x-ray
- B. Gastric analysis
- C. Endoscopy
- D. Barium studies
Correct Answer: C
Rationale: Endoscopy directly visualizes the gastric mucosa, allowing for biopsy and definitive diagnosis of a peptic ulcer, making it the most reliable method.
The nurse is assessing a client with suspected pneumothorax. Which of the following findings would the nurse expect?
- A. Bilateral wheezing.
- B. Decreased breath sounds on one side.
- C. Clear, resonant percussion sounds.
- D. Slow, shallow respirations.
Correct Answer: B
Rationale: decreased breath sounds on the affected side are a hallmark of pneumothorax due to lung collapse
The nurse is reviewing labs on a group of adult clients. Which lab value would prompt the nurse to immediately notify the health care provider?
- A. hemoglobin 4.8 g/dL
- B. troponin T 0.04 ng/mL
- C. phosphorus 3.8 mg/dL
- D. bilirubin (total) 0.7 mg/dL
Correct Answer: A
Rationale: Hemoglobin of 4.8 g/dL is critically low, indicating severe anemia and requiring immediate provider notification. Other values are normal or near-normal.
A 68-year-old client states he decided not to take the herpes zoster (shingles) immunization because his friend had the immunization and still developed shingles. Which of the following information should the nurse include when discussing this issue with the client? Select all that apply.
- A. Shingles rarely occurs after immunization.
- B. The immunization decreases the severity of infection.
- C. The immunization decreases the likelihood of postherpetic syndrome.
- D. The immunization cuts the chance of developing shingles in half.
- E. The client should never take advice from friends.
Correct Answer: B,C,D
Rationale: The shingles vaccine reduces severity (B), postherpetic syndrome risk (C), and shingles incidence by about 50% (D). It doesn't eliminate risk (A), and dismissing friends' advice (E) is inappropriate.