Nokea
The nurse assesses a 72 year-old client who was admitted for right-sided congestive heart failure. Which of the following would the nurse anticipate finding?
- A. Decreased urinary output
- B. Jugular vein distention
- C. Pleural effusion
- D. Bibasilar crackles
Correct Answer: B
Rationale: Signs of right-sided heart failure include jugular vein distention, ascites, nausea, and vomiting.
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A client has been diagnosed with Zollinger-Ellison syndrome. Which information is most important for the nurse to reinforce?
- A. It is a condition in which one or more tumors called gastrinomas form in the pancreas or in the upper part of the small intestine (duodenum)
- B. It is critical to report promptly to your health care provider any findings of peptic ulcers
- C. Treatment consists of medications to reduce acid and heal any peptic ulcers and, if possible, surgery to remove any tumors
- D. With the average age at diagnosis at 50 years the peptic ulcers may occur at unusual areas of the stomach or intestine
Correct Answer: B
Rationale: It is critical to report promptly to your health care provider any findings of peptic ulcers. Such findings include night-time awakening with burning, cramp-like abdominal pain, vomiting and even hematemesis, and change in appetite.
The infection control nurse receives hospital laboratory confirmation that the client has positive sputum cultures for mycobacterium tuberculosis. Which action should be taken by the nurse?
- A. Prepare a statement for the hospital spokesperson to release to the news agencies
- B. Recommend that only staff with recent negative tuberculin skin tests provide care
- C. Implement measures to notify the local or state health department about the case
- D. Notify the nearest infectious disease facility and prepare the client for transfer
Correct Answer: C
Rationale: C: TB is a reportable disease, requiring health department notification. A: Media release is inappropriate. B: All staff can provide care with precautions. D: Transfer is unnecessary.
The clinic nurse encounters the client who has a congested cough and rhinorrhea. The nurse follows droplet precautions/cough protocol by taking which action? Select all that apply.
- A. Offering the client sterile disposable tissues
- B. Wearing a mask while examining the client
- C. Offering the client water to drink while waiting
- D. Teaching how to cover the mouth when coughing
- E. Performing hand hygiene before and after client contact
- F. Separating the client by at least 3 feet from others in the area
Correct Answer: B,D,E,F
Rationale: B: A mask is required during examination to prevent droplet transmission. D: Teaching cough etiquette reduces spread. E: Hand hygiene prevents pathogen transmission. F: Maintaining 3 feet distance reduces droplet spread. A: Sterile tissues are unnecessary. C: Water does not limit transmission.
A client has received 2 units of whole blood today following an episode of GI bleeding. Which of the following laboratory reports would the nurse monitor most closely?
- A. Bleeding time
- B. Hemoglobin and hematocrit
- C. White blood cells
- D. Platelets
Correct Answer: B
Rationale: Hemoglobin and hematocrit. The post-transfusion hematocrit provides immediate information about red cell replacement and about continued blood loss.
A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to
- A. have the client identify coping methods
- B. get the description of the location and intensity of the pain
- C. accept the client's report of pain
- D. determine the client's status of pain
Correct Answer: C
Rationale: accept the client's report of pain. Although all of the options above are correct, the first and most important piece of information in this client's pain assessment is what the client is telling you about the pain -- 'the client's report.'