Nokea
The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His partner states he fell down the stairs 2 hours ago. The nurse should
- A. place a call to the client's provider for instructions
- B. send him to the emergency room for evaluation
- C. reassure the client's partner that the symptoms are transient
- D. instruct the client's partner to call the provider if his symptoms become worse
Correct Answer: B
Rationale: This client requires immediate evaluation. A delay in treatment could result in further deterioration of his condition and possibly permanent harm. Home care nurses must prioritize interventions based on assessment findings that are in the client's best interest.
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The nurse responds to a train derailment.
After making an initial assessment, which of the following clients should the nurse see FIRST?
- A. A pregnant woman who states that her clothing is wet.
- B. A young man with blood pulsating from a cut on the right leg.
- C. A preschool child who is screaming and crying uncontrollably.
- D. An unconscious woman with the right leg shorter than the left leg.
Correct Answer: B
Rationale: Strategy: Think ABCs. (1) requires further assessment, could be amniotic fluid or it could be urine (2) correct-indicates arterial bleeding; apply direct pressure; high risk for shock (3) stable patient (4) possible hip fracture, no indication of respiratory difficulty stated
The nurse is teaching a client with a new diagnosis of type 2 diabetes about insulin detemir (Levemir). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this insulin at bedtime.
- B. I should rotate injection sites.
- C. I should refrigerate unopened vials.
- D. I should take this insulin when my blood sugar is high.
Correct Answer: D
Rationale: Taking insulin detemir when blood sugar is high is incorrect, as it is a long-acting basal insulin for steady control, not for acute hyperglycemia. Options A, B, and C are correct: bedtime dosing is standard, rotation prevents lipodystrophy, and refrigeration preserves insulin.
An adult is thought to have myasthenia gravis. The nurse knows that which test is most likely to be ordered for the client?
- A. Lumbar puncture
- B. CT scan
- C. Cerebral angiogram
- D. Edrophonium (Tensilon) test
Correct Answer: D
Rationale: The edrophonium test, which temporarily improves muscle strength in myasthenia gravis, confirms diagnosis by enhancing neuromuscular transmission, unlike imaging or lumbar puncture.
A postoperative client has a nasogastric (NG) tube following bowel surgery. The orders read, 'acetaminophen 650 PRN for fever above 101°F.' The client has a temperature of 101.4°F. What is the most appropriate nursing action?
- A. Administer the acetaminophen by rectal suppository.
- B. Administer the acetaminophen by elixir through the NG tube and turn suction off for 30 minutes.
- C. Administer the acetaminophen by crushing two tablets, giving it through the NG tube, and turning suction off for 30 minutes.
- D. Call the physician and question the order.
Correct Answer: A
Rationale: A rectal suppository is appropriate with an NG tube on suction, ensuring fever treatment without risking medication loss.
During the second session of individual therapy, a client sits quietly with arms folded and eyes cast down.
Which of the following statements by the nurse is BEST?
- A. What is the weather like outside?
- B. Do you not want to talk with me today?
- C. Are you cold sitting here?
- D. You seem to be feeling sad today.
Correct Answer: D
Rationale: Strategy: 'BEST' indicates that this is a priority question. Remember therapeutic communication. (1) is used to get client comfortable, but would not help to focus on what is important (2) focusing on client's difficulty speaking may make him defensive and block communication (3) concrete questions will encourage client to give yes/no answers, factual answers may block communication of feelings (4) correct-reflection allows client to verbalize feelings