Nokea
The client screams at the nurse, 'You are all incompetent here! I have been waiting for 2 hours!' How should the nurse respond initially?
- A. I know you are upset, but I will have to call security if you continue to scream.
- B. I see that you are frustrated, but the delay cannot be avoided.
- C. It is upsetting to wait so long. How can I best help you?
- D. The wait is long today, but you will receive quality, unhurried care when it is your turn.
Correct Answer: C
Rationale: Acknowledging the client's frustration and offering assistance de-escalates the situation and focuses on solutions. Threatening security escalates tension, and the other options dismiss the client's feelings or fail to address the issue.
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An adult who is hospitalized with congestive heart failure is receiving an intravenous infusion. The nurse is checking the IV. Which of the following is of greatest concern to the nurse?
- A. The insertion site
- B. The volume infused
- C. The frequency with which the tubing is changed
- D. The presence of a flashback
Correct Answer: A
Rationale: The insertion site is critical to assess for infection, infiltration, or phlebitis, the greatest concern to prevent IV complications in heart failure.
A client experiences post partum hemorrhage eight hours after the birth of twins. Following administration of IV fluids and 500 ml of whole blood, her hemoglobin and hematocrit are within normal limits. She asks the nurse whether she should continue to breast feed the infants. Which of the following is based on sound rationale?
- A. Nursing will help contract the uterus and reduce your risk of bleeding.
- B. Breastfeeding twins will take too much energy after the hemorrhage.
- C. The blood transfusion may increase the risks to you and the babies.
- D. Lactation should be delayed until the 'real milk' is secreted.
Correct Answer: A
Rationale: Stimulation of the breast during nursing releases oxytocin, which contracts the uterus, reducing the risk of further bleeding.
When counseling parents of a child who has recently been diagnosed with hemophilia, what must the nurse know about the offspring of a normal father and a carrier mother?
- A. It is likely that all sons are affected
- B. There is a 50% probability that sons will have the disease
- C. Every daughter is likely to be a carrier
- D. There is a 25% chance a daughter will be a carrier
Correct Answer: D
Rationale: There is a 25% chance a daughter will be a carrier. Hemophilia A is sex-linked recessive, with a 25% chance of a carrier female per pregnancy.
The nurse is talking with the family of an 18 months-old newly diagnosed with retinoblastoma. A priority in communicating with the parents is
- A. Discuss the need for genetic counseling
- B. Inform them that combined therapy is seldom effective
- C. Prepare for the child's permanent disfigurement
- D. Suggest that total blindness may follow surgery
Correct Answer: A
Rationale: Discuss the need for genetic counseling. The hereditary aspects of this disease are well documented. While the parents focus on the needs of this child, they should be aware that the risk is high for future offspring.
A client with hypertension and type 2 diabetes has recently started taking chlorthalidone. Which report by the client is most concerning to the nurse?
- A. Dizziness on standing
- B. Fasting blood glucose of 180 mg/dL (10.0 mmol/L)
- C. Presence of muscle cramps
- D. Sunburn on both arms
Correct Answer: A
Rationale: Dizziness on standing suggests orthostatic hypotension, a serious side effect of chlorthalidone, which can lead to falls. Elevated glucose and muscle cramps are concerning but less urgent, and sunburn is unrelated.