Nokea
A nurse is conducting an initial assessment of a client and notices a discrepancy between the client's current IV infusion and the information received during the shift report. Which of the following actions should the nurse take?
- A. Contact the charge nurse to see if the prescription was changed
- B. Complete an incident report and place it in the client's medical record
- C. Submit a written warning for the nurse involved in the incident
- D. Compare the current infusion with the prescription in the client's medication record
Correct Answer: D
Rationale: The correct answer is D: Compare the current infusion with the prescription in the client's medication record. This is the best course of action as it allows the nurse to verify the accuracy of the IV infusion against the prescribed treatment plan. By cross-referencing the current infusion with the prescription in the client's medication record, the nurse can identify any discrepancies and take appropriate actions to ensure the client's safety and well-being.
Choice A is incorrect because contacting the charge nurse may not provide the necessary information to verify the accuracy of the IV infusion. Choice B is incorrect as completing an incident report is premature without first verifying the discrepancy. Choice C is inappropriate and punitive without a proper investigation. Choices E, F, and G are not provided in the question, so they are irrelevant.
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A nurse is caring for a client who has heart failure. Which of the following manifestations should the nurse expect?
- A. Crackles in lungs
- B. Decreased thirst
- C. Poor skin turgor
- D. Tachycardia
Correct Answer: A
Rationale: The correct answer is A: Crackles in lungs. In heart failure, the heart's inability to pump effectively leads to fluid accumulation in the lungs, causing crackles on auscultation. Decreased thirst (B) is not a typical manifestation. Poor skin turgor (C) is more indicative of dehydration. Tachycardia (D) may occur but is not specific to heart failure.
Drag words from the choices below to fill in each blank in the following sentence. The client is at greatest risk for developing-----and-----
- A. Placental Abruption
- B. Hypoglycemia
- C. Heart failure
- D. Cervical insufficiency
- E. Seizures
Correct Answer: C,E
Rationale: The correct answer is C, Heart failure, and E, Seizures. The client is at greatest risk for developing heart failure and seizures due to complications during pregnancy. Heart failure can occur due to the increased stress on the heart from pregnancy, especially in individuals with pre-existing heart conditions. Seizures can arise from conditions like eclampsia, which is a severe form of preeclampsia characterized by high blood pressure and organ damage. Placental abruption (A) is a separation of the placenta from the uterus, not directly related to heart failure or seizures. Hypoglycemia (B) is low blood sugar levels, which may occur but is not the greatest risk in this scenario. Cervical insufficiency (D) is the inability of the cervix to stay closed during pregnancy, which is not directly linked to heart failure or seizures.
A nurse is speaking with the caregiver of a client who has Alzheimer's disease. The caregiver states, 'Providing constant care is very stressful and is affecting all areas of my life.' Which of the following actions should the nurse take?
- A. Suggest that the caregiver seek a prescription for an antipsychotic medication for the client.
- B. Recommend allowing the client to have time alone in their room throughout the day
- C. Discuss methods of how to communicate with the client about resolving problem behaviors
- D. Assist the caregiver to arrange for a daycare program for the client
Correct Answer: D
Rationale: The correct answer is D: Assist the caregiver to arrange for a daycare program for the client. This option addresses the caregiver's concern of stress and the impact on their life by providing respite care. This allows the caregiver to have a break and attend to their own needs while ensuring the client's safety and well-being. It promotes caregiver self-care and prevents burnout.
Option A is incorrect as prescribing antipsychotic medication is not appropriate for caregiver stress. Option B may not address the caregiver's need for a break or support. Option C, while important, focuses on communication strategies rather than providing immediate relief for the caregiver.
For each assessment finding, click to specify if the finding is consistent with psychosis or mania. Each finding may support more than one diagnosis.
- A. Hallucinations
- B. Lack of sleep
- C. Excessive spending habits
- D. Disorganized thought process
- E. Pressured speech
Correct Answer: A: Psychosis; B, C, D, E: Mania
Rationale: The correct answer is A: Psychosis; B, C, D, E: Mania. Hallucinations are typically associated with psychosis due to perceptual disturbances. Lack of sleep, excessive spending habits, disorganized thought process, and pressured speech are all characteristic features of mania, which is a key symptom of Bipolar Disorder. Mania involves elevated mood, increased energy levels, impulsivity, and risky behavior, such as excessive spending. Disorganized thought process and pressured speech are manifestations of the racing thoughts and flight of ideas seen in mania. In summary, while hallucinations are consistent with psychosis, the other findings (lack of sleep, excessive spending habits, disorganized thought process, pressured speech) are more indicative of mania due to the presence of manic symptoms.
A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching?
- A. Bleeding gums
- B. Faintness upon rising
- C. Urinary frequency
- D. Swelling of the face
Correct Answer: D
Rationale: The correct answer is D: Swelling of the face. At 14 weeks of gestation, facial swelling could indicate preeclampsia, a serious condition characterized by high blood pressure and protein in the urine. This finding should be reported to the provider immediately for further evaluation and management to prevent complications for both the mother and the baby.
Other choices are incorrect because:
A: Bleeding gums are common during pregnancy due to hormonal changes and increased blood flow to the gums.
B: Faintness upon rising may be due to postural hypotension, common in pregnancy.
C: Urinary frequency is a common complaint in early pregnancy due to hormonal changes and pressure on the bladder from the growing uterus.