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The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective, and must be reported by the nurse immediately to the provider?
- A. nausea and vomiting
- B. fever of 103 degrees Fahrenheit (39.5 degrees Celsius)
- C. diffuse macular rash
- D. muscle tenderness
Correct Answer: B
Rationale: fever of 103 degrees Fahrenheit (39.5 degrees Celsius). Persistent, prolonged fever may be an indication that the antibiotics are not effective and may need to be changed.
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A 4 year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do first?
- A. Notify the health care provider
- B. Readjust the traction
- C. Administer the ordered prn medication
- D. Reassess the foot in fifteen minutes
Correct Answer: A
Rationale: Notify the health care provider. The findings are indicative of circulatory impairment. The health care provider must be notified immediately.
A nurse is working with a client in an extended care facility. Which bed position is preferred for a client, who is at risk for falls, as part of a prevention protocol?
- A. All 4 side rails up, wheels locked, bed closest to door
- B. Lower side rails up, bed facing doorway
- C. Knee-high, head slightly elevated, bed in lowest position
- D. Bed in lowest position, wheels locked, place bed against wall
Correct Answer: D
Rationale: Bed in lowest position, wheels locked, place bed against wall. Using all 4 side rails is considered a restraint and limits client autonomy unless medically necessary with an order. Lower side rails alone do not adequately prevent falls. The bed in the lowest position with wheels locked and placed against the wall minimizes fall risk while allowing the client freedom of movement.
The nurse is caring for a client who requires a mechanical ventilator for breathing. The high pressure alarm goes off on the ventilator. What is the first action the nurse should perform?
- A. Disconnect the client from the ventilator and use a manual resuscitation bag
- B. Perform a quick assessment of the client's condition
- C. Call the respiratory therapist for help
- D. Press the alarm re-set button on the ventilator
Correct Answer: B
Rationale: A number of situations can cause the high pressure alarm to sound. It can be as simple as the client coughing. A quick assessment of the client will alert the nurse to whether it is a more serious or complex situation that might then require using a manual resuscitation bag and calling the respiratory therapist.
An elderly client admitted after a fall begins to seize and loses consciousness. What action by the nurse is appropriate to do next?
- A. Stay with client and observe for airway obstruction
- B. Collect pillows and pad the side rails of the bed
- C. Place an oral airway and use the body
- D. Announce a cardiac arrest, and assist with intubation
Correct Answer: A
Rationale: Stay with client and observe for airway obstruction. For the client's safety, remain at the bedside and observe respirations and level of consciousness. Prepare to clear the airway if obstructed. Do not place anything in the client's mouth. For safety, do not leave the client unattended. A cardiac arrest should only be announced if pulse or respirations are absent after the seizure.
A client is recovering from a hip replacement and is taking Tylenol #3 every 3 hours for pain. In checking the client, which finding suggests a side effect of the analgesic?
- A. Bruising at the operative site
- B. Elevated heart rate
- C. Decreased platelet count
- D. No bowel movement for 3 days
Correct Answer: D
Rationale: No bowel movement for 3 days. With opioid analgesics, observe for respiratory depression, sedation, and constipation. Bruising is not related to the analgesic, but could be the result of corticosteroids or previously used anticoagulants. Elevated heart rate could be the result of bronchodilators. Some antibiotics can lower platelet count.