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The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respirations 30. Which action by the nurse should receive priority?
- A. Continue monitoring the vital signs
- B. Contact the physician
- C. Ask the client how they feel
- D. Ask the LPN to continue post-op care
Correct Answer: B
Rationale: The priority action for the nurse is to contact the physician immediately due to the client's abnormal vital signs. A blood pressure of 90/50, pulse of 132, and respirations of 30 indicate instability and require prompt medical attention. Continuing to monitor vital signs, as in choice A, may lead to a delay in necessary interventions. Asking the client how they feel, as in choice C, provides subjective data and does not address the urgent need for medical intervention. Involving the LPN, as in choice D, is not appropriate in this critical situation where the client's condition is unstable and requires immediate physician assessment and intervention.
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During the history assessment of an 80-year-old client, which statement made by the client might indicate a possible fluid and electrolyte imbalance?
- A. "My skin is always so dry."?
- B. "I often use a laxative for constipation."?
- C. "I have always liked to drink a lot of iced tea."?
- D. "I sometimes have a problem with dribbling urine."?
Correct Answer: B
Rationale: The correct answer is "I often use a laxative for constipation." Frequent use of laxatives can lead to diarrhea and electrolyte loss, indicating a possible fluid and electrolyte imbalance. Statements A, C, and D are not directly related to fluid and electrolyte imbalance. Statement A about dry skin may suggest dehydration, but it is less specific to electrolyte imbalance than the frequent use of laxatives. Statement C about drinking a lot of iced tea could potentially relate to fluid intake, but it doesn't directly indicate an imbalance. Statement D about dribbling urine is more indicative of a potential urinary issue rather than a fluid and electrolyte imbalance.
The nurse is preparing a client for surgery. Which item is most important to remove before sending the client to surgery?
- A. Hearing aid
- B. Contact lenses
- C. Wedding ring
- D. Artificial eye
Correct Answer: B
Rationale: The correct answer is B: Contact lenses. It is crucial to remove contact lenses before surgery to prevent corneal drying, especially with non-extended wear lenses. Leaving the hearing aid or artificial eye in place does not pose harm to the client during surgery. While wedding rings are typically covered with tape, leaving them on is acceptable. Therefore, choices A, C, and D are incorrect in this scenario.
During discharge teaching for a client with diverticulitis on a low-roughage diet, which food should be eliminated from the diet?
- A. Roasted chicken
- B. Noodles
- C. Cooked broccoli
- D. Custard
Correct Answer: C
Rationale: The client with diverticulitis needs to avoid gas-forming foods that can increase abdominal discomfort. Cooked broccoli is a high-fiber food that can worsen symptoms. Roasted chicken, noodles, and custard are suitable choices for a low-roughage diet as they are less likely to cause gas formation or abdominal discomfort.
Which information should be reported to the state Board of Nursing?
- A. The facility fails to provide literature in both Spanish and English.
- B. The narcotic count has been incorrect on the unit for the past 3 days.
- C. The client fails to receive an itemized account of his bills and services received during his hospital stay.
- D. The nursing assistant assigned to the client with hepatitis fails to feed the client and give the bath.
Correct Answer: B
Rationale: The correct answer is 'The narcotic count has been incorrect on the unit for the past 3 days.' This information should be reported to the state Board of Nursing as it involves medication errors and potential drug diversion, which are serious issues that fall under the jurisdiction of the Board. Reporting medication discrepancies and errors in narcotic counts is crucial for patient safety and regulatory compliance. Choices A, C, and D involve different types of issues that are not within the direct purview of the Board of Nursing. Providing literature in multiple languages (Choice A), addressing billing practices (Choice C), and resolving staff performance issues (Choice D) should be handled internally or reported to the appropriate departments or authorities, such as the Joint Commission or the charge nurse.
The nurse is working with families who have been displaced by a fire in an apartment complex. What is the priority intervention during the initial assessment?
- A. Provide a liaison to meet housing needs.
- B. Attentively listen when clients describe their feelings.
- C. Offer nurturing support for clients who are confused by the events.
- D. Provide structure for clients exhibiting moderate to severe anxiety.
Correct Answer: A
Rationale: The correct answer is to provide a liaison to meet housing needs. In the initial assessment after a disaster like a fire, ensuring basic needs such as housing, clothing, and food are met is the priority. Once the physical needs are addressed, the nurse can then focus on assisting clients in managing the psychological effects of loss. Choices B, C, and D are not the priority during the initial assessment as addressing housing needs should come first to provide a sense of stability and security for the affected families.