Nokea
The home health nurse visits a 72-year-old client with pneumonia who was discharged from the hospital 3 days ago. The client has less of a productive cough at night but now reports sharp chest pain with inspiration. Which finding is most important for the nurse to report to the supervising registered nurse?
- A. Bronchial breath sounds
- B. Increased tactile fremitus
- C. Low-pitched wheezing (rhonchi)
- D. Pleural friction rub
Correct Answer: D
Rationale: Pleural friction rub (D) indicates pleuritis or pleural effusion, a serious complication requiring immediate reporting. Other findings (A, B, C) are less specific or urgent.
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The nurse reinforces education to the parent of a child who was diagnosed with attention-deficit hyperactivity disorder and received a prescription of methylphenidate. Which statement by the parent best demonstrates that teaching has been effective?
- A. An additive-free, low-sugar diet will reduce my child's symptoms.'
- B. I can now manage my child's condition on my own.'
- C. My child should take the last daily dose of methylphenidate before 6:00 PM.'
- D. Once the medication is started, I will not have to monitor my child anymore.'
Correct Answer: C
Rationale: Taking methylphenidate before 6:00 PM (C) prevents sleep disruption, indicating effective teaching. Diet changes (A), self-management (B), and no monitoring (D) are incorrect or incomplete.
The nurse is inserting an indwelling urinary catheter for a male client. After inserting the catheter 6 inches (15.2 cm), the nurse notes a small amount of urine in the tubing. Which of the following actions should the nurse take next?
- A. Measure the urine output.
- B. Immediately inflate the balloon.
- C. Secure the catheter tubing to the client's leg.
- D. Continue to advance the catheter to the bifurcation.
Correct Answer: D
Rationale: Advancing to the bifurcation (D) ensures proper placement in the bladder before inflating the balloon. Measuring output (A), inflating early (B), or securing (C) are premature.
Laboratory reference ranges
INR (Therapeutic – atrial fibrillation)
2.0-3.0
The nurse has reinforced teaching for a client with atrial fibrillation who is receiving warfarin. Which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply.
- A. Antibiotics can affect my INR value.'
- B. I am going to eat more leafy green vegetables.'
- C. I will take the medication at the same time every day.'
- D. I understand that my INR value should be between 4 and 5.'
- E. If I miss a dose of medication, I'll double my dose the next day.'
Correct Answer: A, C
Rationale: Antibiotics affecting INR (A) and consistent timing (C) are correct. More leafy greens (B) can lower INR, INR of 4-5 (D) is too high, and doubling doses (E) is dangerous.
An adult is admitted to the emergency department following a fall. A piece of bone is protruding through the skin of the left thigh. In addition to assessing vital signs, what information is most essential to obtain from the client at this time?
- A. History of previous falls and fractures
- B. Date of last tetanus shot
- C. Type of environment where the fall took place
- D. Any previous surgeries
Correct Answer: B
Rationale: An open fracture (bone protruding) risks tetanus infection; knowing the last tetanus shot date is critical to determine prophylaxis need. Fall history, environment, or surgeries are secondary.
Following an arteriogram, the nurse should give priority to:
- A. Allowing the client to rest
- B. Administering O2 via nasal mask
- C. Checking the ECG monitor
- D. Checking the pulses distal to the catheterization site
Correct Answer: D
Rationale: Checking distal pulses ensures adequate circulation post-arteriogram, as the procedure involves arterial puncture, which can lead to complications like hematoma or thrombosis.