Nokea
The charge nurse overhears the patient care assistant speaking harshly to the client with dementia. The charge nurse should:
- A. Change the nursing assistant's assignment
- B. Explore the interaction with the nursing assistant
- C. Discuss the matter with the client's family
- D. Initiate a group session with the nursing assistant
Correct Answer: B
Rationale: Exploring the interaction addresses the behavior appropriately.
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A client is admitted with suspected pernicious anemia. Which findings support the diagnosis of pernicious anemia?
- A. The client complains of feeling tired and listless.
- B. The client has waxy, pale skin.
- C. The client exhibits loss of coordination and position sense.
- D. The client has a rapid pulse rate and a detectable heart murmur.
Correct Answer: C
Rationale: Loss of coordination and position sense are neurological symptoms due to vitamin B12 deficiency in pernicious anemia.
The nurse has an order to give 1,000 mL of 0.9% NS with 20 meQ of potassium chloride over 8 hours. The IV set has a drop factor of 15. How many gtts/min should the client receive?
Correct Answer: 31
Rationale: Rate = 1,000 mL ÷ 8 hr = 125 mL/hr. Drops/min = (125 mL/hr × 15 gtts/mL) ÷ 60 min = 31.25 gtts/min, rounded to 31 gtts/min.
A client is confused after receiving morphine for analgesia and repeatedly tries to pull out the intravenous (IV) line in her left arm. Which of the following actions is the best initial solution?
- A. Attempt to camouflage the IV and tie a piece of tubing to the bedrail so the client can pull on that safely.
- B. Apply wrist restraints.
- C. Apply wrist and vest restraints.
- D. Discontinue the IV line and reinsert at a more distant site.
Correct Answer: A
Rationale: Camouflaging the IV and providing a safe alternative (A) is a least-restrictive, non-invasive initial approach to prevent the client from pulling out the IV. Restraints (B, C) should be a last resort, and discontinuing the IV (D) is unnecessary.
A client is 4 hours post-op left carotid endarterectomy. Which assessment finding would cause the nurse the most concern?
- A. Temperature 99.4°F, heart rate 110, respiratory rate 24
- B. Drowsiness, urinary output of 50 mL the past hour, 1 cm blood drainage noted on surgical dressing
- C. BP 120/60, lethargic, right-sided weakness
- D. Alert and oriented, BP 168/96, heart rate 70
Correct Answer: C
Rationale: Right-sided weakness post-left carotid endarterectomy suggests a neurological deficit, possibly from stroke or hematoma, requiring immediate intervention.
A client is admitted to the emergency room with multiple injuries. What is the proper sequence for managing the client?
- A. Assess for head injuries, control hemorrhage, establish an airway, prevent hypovolemic shock
- B. Control hemorrhage, prevent hypovolemic shock, establish an airway, assess for head injuries
- C. Establish an airway, control hemorrhage, prevent hypovolemic shock, assess for head injuries
- D. Prevent hypovolemic shock, assess for head injuries, establish an airway, control hemorrhage
Correct Answer: C
Rationale: The ABCs of trauma care prioritize airway, breathing, and circulation. Establishing an airway comes first, followed by controlling hemorrhage and preventing shock, then assessing for head injuries.