Nokea
The home health nurse is planning for the day's visits. Which client should be seen first?
- A. The 78-year-old who had a gastrectomy 3 weeks ago and has a PEG tube
- B. The 5-month-old discharged 1 week ago with pneumonia who is being treated with amoxicillin liquid suspension
- C. The 50-year-old with MRSA being treated with Vancomycin via a PICC line
- D. The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter
Correct Answer: B
Rationale: The 5-month-old with recent pneumonia is at high risk for complications, prioritizing their assessment.
You may also like to solve these questions
The nurse is caring for a client post-op femoral popliteal bypass graft. Which post-operative assessment finding would require immediate physician notification?
- A. Edema of the extremity and pain at the incision site
- B. A temperature of 99.6°F and redness of the incision
- C. Serous drainage noted at the surgical area
- D. A loss of posterior tibial and dorsalis pedis pulses
Correct Answer: D
Rationale: Loss of distal pulses indicates potential graft occlusion or arterial compromise, a surgical emergency requiring immediate notification.
The nurse is caring for a client admitted with chest pain and atrial fibrillation. The nurse accidentally gives the client the wrong dose of digoxin. The client is monitored throughout the shift and no ill effects are noted. Which actions by the nurse are correct? Select all that apply.
- A. fill out an incident report and make a note of it in the nurse's notes
- B. print out rhythm strips every 2 hours and place on the client's chart
- C. fill out an incident report and notify the health care provider for further orders
- D. notify the health care provider at the end of the shift, since no ill effects were observed
- E. notify the pharmacy that they loaded the wrong dose in the automatic medication dispensing system
Correct Answer: C
Rationale: Filling out an incident report and notifying the provider immediately are necessary to address the medication error and ensure client safety, even if no ill effects were observed.
When determining whether or not a client is a candidate for restraints, which of the following would be considered an appropriate reason for a restraint?
- A. Current dangerous behavior
- B. History of falls
- C. Recent violent attack on a staff member
- D. Refusal to cooperate with treatment
Correct Answer: A
Rationale: Restraints are justified for current dangerous behavior (A) posing immediate risk to self or others. History of falls (B), past violence (C), or non-cooperation (D) do not warrant restraints.
The nurse is caring for a client with a wound that presents with full-thickness tissue loss and eschar covering the wound bed. The nurse would record this wound as which stage?
- A. Stage I
- B. Stage II
- C. Stage III
- D. Stage IV
- E. unstageable
Correct Answer: E
Rationale: Eschar covering the wound bed makes it unstageable, as the depth cannot be assessed until debridement.
A client admitted for treatment of a deep venous thrombosis of the calf complains of dyspnea and chest pain. What is the best response by the nurse?
- A. administer oxygen at 2 L/min as ordered prn
- B. place client in a semi-Fowler's position
- C. prepare client for diagnostic tests
- D. obtain vital signs
Correct Answer: C
Rationale: Dyspnea and chest pain suggest a possible pulmonary embolism, a complication of DVT, requiring immediate preparation for diagnostic tests to confirm and treat.