Nokea
The ED nurse is working in triage on a summer weekend. The following clients present at the same time. Which client does the nurse anticipate being seen first?
- A. a 58-year-old man with abdominal pain and nausea
- B. an infant with fever, a shrill cry, diarrhea, and nuchal rigidity
- C. a 38-year-old jogger who twisted her ankle, has a good pedal pulse, and has no deformity
- D. a 46-year-old client who was working outside and has tachypnea, diaphoresis, and fatigue
- E. an ambulatory child who fell off a bicycle and hit his head on grass while wearing a helmet
Correct Answer: B
Rationale: The infant's symptoms suggest meningitis, a life-threatening condition requiring immediate attention.
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The nurse is caring for a middle-aged woman who walks 3 miles every morning. The nurse notes that during her morning walk, the client called her son and stated that she thought she was having a heart attack. Which symptom, identified by the client, is the most common and consistent with a myocardial infarction (MI)?
- A. palpitations
- B. lower extremity edema
- C. uncomfortable feeling of pressure in the chest
- D. nausea
Correct Answer: C
Rationale: Chest pressure is the hallmark symptom of myocardial infarction, often described as a heavy, squeezing, or crushing sensation. Palpitations, edema, and nausea may occur but are less specific.
The nurse is caring for an elderly client who is 1 day post-hip replacement surgery. Which nursing interventions should be included on the care plan? Select all that apply.
- A. apply compression stockings
- B. ambulate with walker
- C. encourage coughing and deep breathing every 2 hours
- D. limit fluid intake
Correct Answer: A,B,C
Rationale: Compression stockings prevent DVT, ambulation promotes recovery, and coughing/deep breathing prevent respiratory complications. Fluid restriction is not indicated.
The newly graduated nurse is caring for an elderly client on the medical-surgical floor. The nurse recalls learning about client advocacy. Which actions by the nurse indicate an understanding of client advocacy? Select all that apply.
- A. The nurse speaks to the daughters regarding caremaking decisions, since the client is elderly and may not understand.
- B. The nurse tells the family that they should really consider making the client an organ donor in case something happens.
- C. The nurse makes sure the client understands treatment options, including possible outcomes if the client refuses treatment.
- D. The nurse obtains an interpreter for the client if her native language is not English and she only understands her native language.
- E. The nurse asks the client for a copy of advance directives or a living will, or provides information if the client does not have one.
Correct Answer: C,D,E
Rationale: Ensuring understanding of treatment options, providing an interpreter, and addressing advance directives respect client autonomy and rights. Bypassing the client or pushing organ donation is not advocacy.
A nurse is preparing a client scheduled for a right mastectomy. Which statement indicates the need for further intervention?
- A. The client refuses to sign the blood consent since she is a Jehovah's Witness.
- B. The client identifies the right breast as the surgical site for a right mastectomy.
- C. The client signs the consent form with an X, which is witnessed by two licensed personnel.
- D. The client expresses doubt over her decision and asks the nurse to explain more about the procedure.
Correct Answer: D
Rationale: Expressing doubt and requesting more explanation about the procedure indicates the client may not fully understand or be comfortable with the surgery, requiring further intervention to ensure informed consent. Options A, B, and C reflect appropriate client actions or standard procedures.