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The medical-surgical nurse cares for a group of clients. Which client situations would prompt the nurse to notify the health care provider during the middle of the night? Select all that apply.
- A. Client develops right-sided upper and lower extremity drift
- B. Client found lying unconscious on the floor
- C. Client has order for heparin with surgery planned for the morning
- D. Client has serum sodium of 124 mEq/L (124 mmol/L)
- E. Client refuses a prescribed, routine pain medication
Correct Answer: A,B,C,D
Rationale: Extremity drift (A), unconsciousness (B), heparin before surgery (C), and severe hyponatremia (D) are urgent and require notification. Refusing pain medication (E) is not critical.
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The nurse has completed teaching the client about his low-sodium, low-fat diet. Which menu, if selected by the client, would indicate to the nurse that the client understands his diet?
- A. Mashed potatoes, spinach, and meatloaf
- B. Swordfish with Hollandaise sauce, carrots, and rice pilaf
- C. Baked chicken, wild rice, and broccoli
- D. Roast beef with gravy, baked potato with sour cream, and creamed peas
Correct Answer: C
Rationale: Baked chicken, wild rice, and broccoli are low in sodium and fat, aligning with the diet. Meatloaf, Hollandaise, and gravy/sour cream/creamed peas are high in sodium or fat.
The nurse preparing an educational seminar on sexually transmitted infections for female college students should advise that which 2 infections are leading causes of pelvic inflammatory disease and infertility?
- A. Genital herpes and HIV
- B. Gonorrhea and chlamydia
- C. Human papillomavirus and syphilis
- D. Yeast and trichomoniasis
Correct Answer: B
Rationale: Gonorrhea and chlamydia (B) are bacterial infections that commonly cause pelvic inflammatory disease and infertility if untreated. Other options are less associated with these outcomes.
A client who is 2 days post-operative from an appendectomy requests medication for pain. The client's vital signs are as follows: pulse 96, respirations 30, BP 130/92. The nurse should:
- A. Ask whether the client is anxious.
- B. Give the pain medication.
- C. Check the dressing for bleeding.
- D. Recheck the client's vital signs.
Correct Answer: B
Rationale: Pain medication is appropriate for a post-op client with pain and stable vitals. Anxiety may contribute, but pain should be addressed first. Bleeding checks or rechecking vitals are unnecessary without specific indicators.
While assisting a doctor with a sterile dressing change, the nurse notices that the doctor has contaminated his left hand. Which action should the nurse take?
- A. Hand the doctor another pair of gloves.
- B. Tell the doctor that he has contaminated his gloves.
- C. Say nothing because the client will be placed on prophylactic antibiotics.
- D. Report the incident to the infection control nurse.
Correct Answer: B
Rationale: Telling the doctor about the contamination maintains sterility and patient safety. Handing gloves assumes he noticed. Antibiotics are not a substitute for sterility. Reporting is secondary to immediate action.
A client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication:
- A. Should be taken in the morning
- B. May decrease the client's energy level
- C. Must be stored in a dark container
- D. Will decrease the client's heart rate
Correct Answer: A
Rationale: Should be taken in the morning. Thyroid supplement should be taken in the morning to minimize the side effect of insomnia.