Nokea
The nurse assesses the new stoma of a client diagnosed with Crohn's disease. Which of these assessment findings will alert the nurse that the stoma has retracted?
- A. Narrowed and flattened
- B. Concave and bowl-shaped
- C. Dry and reddish-purple
- D. Pinkish-red and moist
Correct Answer: B
Rationale: A retracted stoma appears concave and bowl-shaped, indicating it has pulled below the skin surface.
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The nurse is collecting data on a client who is taking prescribed digoxin and furosemide. Which finding requires follow-up?
- A. Night sweats and headache
- B. Vomiting and halos around lights
- C. Fatigue and dry, flaky skin
- D. Low blood pressure and dark urine
Correct Answer: B
Rationale: Vomiting and halos around lights are signs of digoxin toxicity, requiring immediate follow-up.
While preparing to change the dressing of a female patient with end-stage renal disease, the nurse notices that the patient's son is silently holding her hand and praying. Which of the following should be the nurse's initial action?
- A. Continue preparing for the procedure in the room.
- B. Notify the chaplain.
- C. Leave the room quietly and come back after 15 minutes to change the client's dressing.
- D. Ask the son if he wants the nurse to join in prayer.
Correct Answer: C
Rationale: Respecting the spiritual moment, leaving the room quietly allows privacy and maintains dignity.
The following scenario applies to the next 1 items
The nurse in the emergency department (ED) is caring for a 70-year-old client.
Item 1 of 1
Nurses' Notes
1100: Client was brought into the ED via emergency medical services (EMS) after he was found wandering the streets and completely disoriented. He was carrying a wallet and identification. His previous medical history was obtained from medical records—history of atrial fibrillation and diabetes mellitus (type two). On assessment, the client is lethargic, disoriented, and mumbling incoherent words. Breathing appears slightly labored, and wheezes with scattered rhonchi are noted in the bilateral lung fields—productive cough with a large amount of mucous. Skin is hot to touch, pale in tone; pulses 2+ and irregular. The client has an unkempt appearance and is malodorous. Peripheral venous access device (VAD) placed in right forearm. Vital signs: T 102° F (38.9° C), P 92, RR 24, BP 144/89, pulse oximetry reading 91% on room air. Orders received from the physician.
The nurse reviews the physician's orders and plans implementation. For each potential nursing action, click to specify whether the action is a high priority or a low priority.
- A. Educate the client on using the incentive spirometer
- B. Perform a head-to-toe skin assessment
- C. Notify radiology to obtain the portable chest radiograph (x-ray)
- D. Administer albuterol via nebulizer
- E. Apply supplemental oxygen via nasal cannula
- F. Collect ordered laboratory work (CBC, CMP, blood cultures)
- G. Perform admission medication reconciliation
Correct Answer: C, D, E, F (high priority); A, B, G (low priority)
Rationale: High priority: Chest x-ray, albuterol, oxygen, and labs address acute respiratory distress and infection. Low priority: Spirometer education, skin assessment, and medication reconciliation can be delayed.
The charge nurse has received a change-of-shift report on the following clients in the maternity unit. The nurse should first assess the client who
- A. delivered a term newborn 2 days ago and reports sweating and increased urinary frequency
- B. is 15 weeks pregnant and is being treated for hyperemesis gravidarum and reports increased nausea following a meal
- C. is 32 weeks pregnant and admitted 2 hours ago with placenta previa, who reports increased lower back pain
- D. is in the first stage of labor, and the most recent fetal heart rate pattern showed early decelerations
Correct Answer: C
Rationale: Increased lower back pain in a client with placenta previa at 32 weeks suggests possible complications like bleeding, requiring immediate assessment.
The nurse is caring for a four-year-old child. While developing a plan of care, the nurse recognizes the child is in which stage of Erikson's stages of psychosocial development?
- A. Initiative vs. Guilt
- B. Autonomy vs. Shame and Doubt
- C. Industry vs. Inferiority
Correct Answer: A
Rationale: A four-year-old is in the Initiative vs. Guilt stage, focusing on exploring and taking initiative.