Nokea
A client with pharyngitis.
The clinic nurse is obtaining a throat culture from a client with pharyngitis. It is MOST important for the nurse to do which of the following?
- A. Quickly rub a cotton swab over both tonsillar areas and the posterior pharynx.
- B. Obtain a sputum container for the client to use.
- C. Irrigate with warm saline, and then swab the pharynx.
- D. Hyperextend the client's head and neck for the procedure.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-tonsillar and pharyngeal areas are quickly swabbed to avoid client discomfort (2) sputum specimen would not reflect throat bacteria (3) should not be done to obtain an adequate culture (4) client should hold the head upright, not hyperextended
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A client who has just indicated a wish to kill herself and asks the nurse not to tell anyone.
The nurse's BEST response should be to
- A. encourage the client not to do anything without thinking it through very carefully.
- B. explain to the client that anything she tells the nurse is kept strictly confidential.
- C. report this to staff members in order to protect the client.
- D. encourage the client to tell the nurse more about what she is feeling.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) does not answer client's immediate concern or give client accurate information about what the nurse will do (2) does not answer client's immediate concern or give client accurate information about what the nurse will do (3) correct-nurse must let the client know that this information will be shared with the staff so that the client's safety can be preserved (4) does not answer client's immediate concern or give client accurate information about what the nurse will do
The nurse is caring for a patient following surgery for a coronary artery bypass graft (CABG). Which of the following symptoms would the nurse expect to see if the patient was in the early stages of circulatory overload?
- A. Change in the character of respirations.
- B. Fluctuation in the blood pressure.
- C. Reduction in tissue turgor.
- D. Increase in body temperature.
Correct Answer: A
Rationale: will see dyspnea, cough, edema, hemoptysis
An elderly client receiving IV fluids of 0.9% NaCl at 125 cc/h into her left arm. During a routine assessment, the nurse finds that the client has distended neck veins, shortness of breath, and crackles in both lung bases.
The nurse should
- A. decrease the IV rate to 20 cc/h and notify the physician.
- B. decrease the IV rate to 100 cc/h and continue to monitor the client.
- C. discontinue the IV and start oxygen at 6 L/min.
- D. assess for infiltration of the IV solution.
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate? No. Determine the outcome of each implementation. (1) correct-KVO (20 cc/h) will keep access open (2) need to notify physician, rate still too much since patient is in fluid overload (3) IV line may be necessary, diuretics may be ordered (4) description indicates circulatory overload, not infiltration
The daughter of a 70-year-old patient with cancer asks the nurse, 'Do you believe in euthanasia?' Which of the following responses by the nurse is BEST?
- A. I think that each person has to decide this issue for herself.
- B. My religion is opposed to euthanasia.
- C. What are your thoughts about euthanasia?
- D. Did you see the TV program about euthanasia last night?
Correct Answer: C
Rationale: open-ended question, allows client to verbalize
Prior to a cesarean section delivery, a 24-year-old woman is treated for abruptio placentae. The nurse is caring for the woman during the postpartum period. Which of the following symptoms would be suggestive of disseminated intravascular coagulation (DIC)?
- A. The client's vital signs are: BP 90/58, temperature 101°F (38.3°C), pulse 112, respirations 18.
- B. The client's laboratory results are: Hgb 13 g/dL, Hct 40%, WBC 7,000/mm³.
- C. The client is nauseated, lethargic, and has vomited three times.
- D. There is oozing blood from the venipuncture site and abdominal incision.
Correct Answer: D
Rationale: DIC is acquired clotting disorder from overstimulation, prolonged oozing from sites of minor trauma first symptom