Nokea
The day shift nurse provides handoff of care report to the oncoming night shift nurse. Which of the following statements by the nurse are appropriate to include in the report? Select all that apply.
- A. I gave acetaminophen 500 mg PO to the client for a headache, with good relief.
- B. The client had morphine 15 mg PO 45 minutes ago for leg pain and now reports 3 on a pain scale of 0-10.
- C. The client's sisters visited today and were very rude, but they did bring the client's medication list.
- D. The continuous bladder irrigation normal saline infusion bag will need to be replaced at 9 PM.
- E. The radiology department called to say that an ultrasound will be performed at 9 PM.
Correct Answer: A,B,D,E
Rationale: Acetaminophen administration (A), morphine effect (B), irrigation replacement (D), and ultrasound schedule (E) are relevant to care. Family behavior (C) is subjective and inappropriate.
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The nurse is caring for a client with suspected acute rheumatic fever. Which of the following questions would be most important for the nurse to ask the client?
- A. Do you typically take all of your antibiotics when they are prescribed?
- B. Has anyone in your family had rheumatic fever?
- C. What has your temperature been over the past several days?
- D. Have you recently had a streptococcal throat infection?
Correct Answer: D
Rationale: Recent streptococcal infection (D) is the primary trigger for rheumatic fever, making it the most important question. Antibiotic compliance (A), family history (B), and fever (C) are relevant but less critical.
The nurse is planning care for an 11-year-old child with attention deficit hyperactivity disorder who is hospitalized for surgical treatment of a fractured femur. What is the priority nursing action?
- A. Create a structured and consistent environment with a daily schedule
- B. Give the child a written schedule of activities
- C. Provide a verbal explanation of what to expect during hospitalization
- D. Restrict visitors while the child is hospitalized
Correct Answer: A
Rationale: A structured environment (A) supports ADHD management by reducing overstimulation and providing predictability, critical for a hospitalized child. Written schedules (B) and verbal explanations (C) are secondary, and restricting visitors (D) is unnecessary.
The nurse is talking with a client who is scheduled for cardiac catheterization. Which of the following findings would be essential to follow up? Select all that apply.
- A. elevated serum C-reactive protein level
- B. previous allergic reaction to IV contrast
- C. prolonged PR interval on ECG
- D. received metformin today for type 2 diabetes mellitus
- E. elevated serum creatinine
Correct Answer: B,D,E
Rationale: Allergy to contrast (B), recent metformin use (D), and elevated creatinine (E) increase risks during cardiac catheterization (anaphylaxis, lactic acidosis, and renal injury). CRP (A) and PR interval (C) are less urgent.
The nurse in the emergency department is caring for a client who has facial lacerations, a suspected fracture of the arm, and multiple bruises at various stages of healing. The client's spouse is at the bedside and appears angry. Which of the following actions would be a priority for the nurse take?
- A. Recommend a referral to social services for the client.
- B. Talk with the client privately without the spouse in the room.
- C. Place the client's arm in a shoulder sling and prepare the client for an x-ray.
- D. Cleanse the client's facial lacerations and prepare to assist with suture placement.
Correct Answer: B
Rationale: Multiple bruises at various stages suggest possible abuse, so talking privately with the client (B) is the priority to assess safety. Social services (A) may follow, but immediate safety assessment comes first. Treating injuries (C, D) is secondary.
The morning weight for a client with emphysema indicates that the client has gained 5 pounds in less than a week, even though his oral intake has been modest. The client's weight gain may reflect which associated complication of COPD?
- A. Polycythemia
- B. Cor pulmonale
- C. Left ventricular failure
- D. Compensated acidosis
Correct Answer: B
Rationale: Rapid weight gain in a client with emphysema, despite modest intake, suggests fluid retention, which is commonly associated with cor pulmonale, a complication of COPD involving right heart failure due to lung disease. Answer A (polycythemia) is a blood disorder, not directly linked to weight gain. Answer C (left ventricular failure) is less likely in COPD compared to cor pulmonale. Answer D (compensated acidosis) does not cause weight gain.