Nokea
The newly graduated nurse is caring for an elderly client on the medical-surgical floor. The nurse recalls learning about client advocacy. Which actions by the nurse indicate an understanding of client advocacy? Select all that apply.
- A. The nurse speaks to the daughters regarding caremaking decisions, since the client is elderly and may not understand.
- B. The nurse tells the family that they should really consider making the client an organ donor in case something happens.
- C. The nurse makes sure the client understands treatment options, including possible outcomes if the client refuses treatment.
- D. The nurse obtains an interpreter for the client if her native language is not English and she only understands her native language.
- E. The nurse asks the client for a copy of advance directives or a living will, or provides information if the client does not have one.
Correct Answer: C,D,E
Rationale: Ensuring understanding of treatment options, obtaining an interpreter, and discussing advance directives promote client autonomy and rights. Other actions assume incapacity or impose personal views.
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The nurse is caring for a client after a motor vehicle accident. The client has a fractured tibia, and bone is noted protruding through the skin. Which action is of priority?
- A. Provide manual traction above and below the leg
- B. Cover the bone area with a sterile dressing
- C. Apply an ACE bandage around the entire lower limb
- D. Place the client in the prone position
Correct Answer: B
Rationale: An open fracture with protruding bone risks infection. Covering with a sterile dressing is the priority to prevent contamination. Traction or bandaging may worsen the injury.
A client is admitted to the emergency room after falling down a flight of stairs. Initial assessment reveals a large bump on the front of the head and a 2-inch laceration above the right eye. Which finding is consistent with injury to the frontal lobe?
- A. Complaints of blindness
- B. Decreased respiratory rate and depth
- C. Failure to recognize touch
- D. Inability to identify sweet taste
Correct Answer: C
Rationale: The frontal lobe is involved in sensory processing and cognition, so failure to recognize touch (agnosia) is consistent with frontal lobe injury.
The nurse is caring for a client with a history of spinal cord injury who is admitted with a urinary tract infection. Which of the following interventions should the nurse implement?
- A. Encourage the client to limit fluid intake.
- B. Administer antibiotics as ordered.
- C. Insert an indwelling catheter.
- D. Restrict the client to bed rest.
Correct Answer: B
Rationale: antibiotics are the primary treatment for a urinary tract infection
A client visiting a family planning clinic is suspected of having an STI. The best diagnostic test for treponema pallidum is:
- A. Venereal Disease Research Lab (VDRL)
- B. Rapid plasma reagin (RPR)
- C. Florescent treponemal antibody (FTA)
- D. Thayer-Martin culture (TMC)
Correct Answer: C
Rationale: The fluorescent treponemal antibody (FTA) test is highly specific for Treponema pallidum, the causative agent of syphilis, and is the best diagnostic test.
The home health nurse is visiting a client who plans to deliver her baby at home. Which statement by the client indicates an understanding regarding screening for phenylketonuria (PKU)?
- A. I will need to take the baby to the clinic within 24 hours of delivery to have blood drawn.
- B. I will need to schedule a home visit for PKU screening when the baby is 3 days old.
- C. I will remind the midwife to save a specimen of cord blood for the PKU test.
- D. I will have the PKU test done when I take her for her first immunizations.
Correct Answer: B
Rationale: PKU screening is typically performed at 2-3 days of age to ensure accurate results, as earlier testing may yield false negatives.