Nokea
The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the discharge list in order to make room for a new admission?
- A. A middle aged client with a 7 year history of being ventilator dependent and who was admitted with bacterial pneumonia five days ago
- B. A young adult with Type 2 diabetes mellitus for over 10 years and who was admitted with antibiotic-induced diarrhea 24 hours ago
- C. An elderly client with a history of hypertension, hypercholesterolemia and lupus, and who was admitted with Stevens-Johnson syndrome that morning
- D. An adolescent with a positive HIV test and who was admitted for acute cellulitis of the lower leg 48 hours ago
Correct Answer: A
Rationale: The best candidate for discharge is one who has a chronic condition and has an established plan of care. The client in option A is most likely stable and could continue medication therapy at home.
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The nurse is working at a student health clinic at a large university. Which of the following signs and symptoms would cause the nurse to suspect cocaine abuse in a 20-year-old college student?
- A. Frequent sneezing, complaints of a sore throat, and a temperature of 100°F (37.8°C).
- B. Diarrhea, vomiting, and abdominal pain.
- C. Fatigue, dilated pupils, and anorexia.
- D. Complaints of insomnia, rhinorrhea, and facial pain.
Correct Answer: D
Rationale: Insomnia, rhinorrhea, and facial pain are associated with cocaine inhalation, the most common administration route. Options A, B, and C are less specific: A suggests infection, B indicates GI issues, and C could apply to other substances.
The nurse is caring for a client with a history of heart failure who is receiving furosemide (Lasix) 40 mg PO daily. Which of the following laboratory results should the nurse report immediately?
- A. Potassium 3.0 mEq/L.
- B. Sodium 140 mEq/L.
- C. Creatinine 1.2 mg/dL.
- D. Glucose 100 mg/dL.
Correct Answer: A
Rationale: Hypokalemia (3.0 mEq/L) from furosemide increases arrhythmia risk in heart failure. Options B, C, and D are normal.
The parents of an infant ask the nurse in the physician's office what diseases the DPT shot protects against. What should the nurse include when replying?
- A. Diarrhea, polio, and typhoid
- B. Diphtheria, whooping cough, and tetanus
- C. Diarrhea, pertussis, and typhus
- D. Diphtheria, paralysis, and tetany
Correct Answer: B
Rationale: The DPT (DTaP) vaccine protects against diphtheria, pertussis (whooping cough), and tetanus. The other options include incorrect diseases.
A client has been admitted with complaints of lower abdominal pain, difficulty swallowing, nausea, dizziness, headache and fatigue. The client is agitated, fearful, tachycardic and complains of being 'too sick to return to work.' The client is diagnosed as having somatoform disorder. In formulating a plan of care, the nurse must consider that the client's behavior
- A. Is controlled by their subconscious mind
- B. Is manipulative to avoid work responsibilities
- C. Would respond to psychoeducational strategies
- D. Could be modified through reality therapy
Correct Answer: A
Rationale: Is controlled by their subconscious mind. Somatoform disorder involves involuntary physical complaints driven by psychological factors, not conscious manipulation.
A client is admitted with acute abdominal pain. Which of the following findings would require immediate attention?
- A. BP 100/50, P 96, abdominal distention
- B. Temperature 99°, flatulence, nausea
- C. Urinary frequency and dysuria
- D. Temperature 99.2°, amber-colored urine
Correct Answer: A
Rationale: Hypotension (BP 100/50), tachycardia (P 96), and abdominal distention suggest a serious condition like internal bleeding or perforation, requiring immediate attention.