Nokea
The client's identification armband was removed to start an I.V. line as a part of the preoperative preparation. The transport team has arrived to transport the client to the operating room. The nurse notices that the client's identification band is not on his wrist. What is the nurse's best response?
- A. Send the removed armband with the chart and the client to the operating room.
- B. Place a new identification armband on the client's wrist before transport.
- C. Tape the cut armband back onto the client's wrist.
- D. Send the client without an armband because she can verbally identify herself.
Correct Answer: B
Rationale: Placing a new identification armband ensures accurate client identification during transport and surgery, maintaining safety and compliance with protocol.
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A client has a platelet count of 31,000/µL. The nurse should instruct the client to:
- A. Pad sharp surfaces to avoid minor trauma when walking.
- B. Assess for spontaneous petechiae in the extremities.
- C. Keep the room darkened.
- D. Check for blood in the urine.
Correct Answer: A
Rationale: A platelet count of 31,000/µL indicates thrombocytopenia, increasing the risk of bleeding from minor trauma. Padding sharp surfaces helps prevent injuries that could lead to bleeding. Assessing for petechiae or checking urine are monitoring actions, not preventive instructions, and darkening the room is unrelated.
The son of a 78-year-old client with metastatic prostate cancer is asking the nurse about the purpose of hospice care. Which of the following statements by the nurse best describes hospice care?
- A. Hospice care uses a team approach to direct hospice activity.
- B. Clients and their families are the focus of care.
- C. The client's physician coordinates all the care.
- D. All hospice clients will die at home.
Correct Answer: B
Rationale: Hospice care focuses on the client and family, providing holistic support to enhance quality of life and comfort during the end-of-life phase.
During the early phase of burn care the nurse should assess the client for?
- A. Hypernatremia.
- B. Hypomatremia.
- C. Metabolic alkalosis.
- D. Hyperkalemia.
Correct Answer: D
Rationale: In the early phase, cell damage from burns releases potassium, causing hyperkalemia. Sodium levels typically decrease (hyponatremia), and metabolic acidosis is more common due to tissue hypoxia.
A 25-year-old client taking hydroxychloroquine (Plaquenil) for rheumatoid arthritis reports difficulty seeing out of her left eye. Correct interpretation of this assessment finding indicates which of the following?
- A. Development of a cataract.
- B. Possible retinal degeneration.
- C. Part of the disease process.
- D. A coincidental occurrence.
Correct Answer: B
Rationale: Hydroxychloroquine can cause retinal toxicity, leading to vision changes. This is a known side effect requiring immediate medical evaluation.
During a home visit, a diabetic client begins to cry and says, 'I just cannot stand the thought of having to give myself a shot every day.' Which of the following would be the best response by the nurse?
- A. If you do not give yourself your insulin shots, you will die.'
- B. We can teach your daughter to give the shots so you will not have to do it.'
- C. I can arrange to have a home care nurse give you the shots every day.'
- D. What is it about giving yourself the insulin shots that bothers you?'
Correct Answer: D
Rationale: Exploring the client's concerns about insulin injections promotes understanding and helps address fears, supporting adherence to treatment.