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The nurse is reviewing client assignments on a medical/surgical unit.
The nurse determines that the assignment is appropriate if the nursing assistant is caring for which of the following clients?
- A. A client with AIDS dementia complex who requires a urine specimen.
- B. A client complaining of postoperative pain after repair of a torn rotator cuff.
- C. A client with GI bleeding due to a duodenal ulcer receiving packed cells.
- D. A client with type I diabetes receiving prednisone for a herniated disk.
Correct Answer: A
Rationale: Strategy: Assign clients with standard, unchanging procedures. (1) correct-standard, unchanging procedure (2) assign to the RN (3) assign to the RN (4) assign to the RN
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A client hospitalized with bipolar disorder, manic phase, begins to talk loudly, pace the floor, and shout commands to others in the day room as he quickly changes the TV channels. The nurse's first action should include:
- A. Checking the client's medication order
- B. Escorting the client from the day room
- C. Placing the client in seclusion
- D. Finding out whether the client's behavior is upsetting others in the day room
Correct Answer: B
Rationale: Escorting the client from the day room de-escalates the situation by removing them from a stimulating environment, reducing agitation.
A pregnant diabetic client, who is 37 weeks gestation, is scheduled for an amniocentesis. The client asks the nurse the purpose of the test. The nurse should explain that the primary reason for performing an amniocentesis is:
- A. To determine the effect of the diabetes on the fetus
- B. To estimate the skeletal age of the fetus
- C. To determine the fetal lung maturity
- D. To obtain information about aberrant fetal genes
Correct Answer: C
Rationale: At 37 weeks, amniocentesis primarily assesses fetal lung maturity via lecithin/sphingomyelin ratio, critical for delivery planning. Diabetes effects , skeletal age , and genetic issues are less common indications.
The nurse is teaching a client with hypertension about dietary modifications. Which of the following foods should the nurse recommend the client avoid?
- A. Baked chicken breast.
- B. Canned vegetable soup.
- C. Fresh apples.
- D. Whole-grain bread.
Correct Answer: B
Rationale: Canned vegetable soup is high in sodium, which can exacerbate hypertension. Options A, C, and D are suitable: baked chicken is low-sodium, apples are heart-healthy, and whole-grain bread supports cardiovascular health.
A client is being treated for hypovolemia.
Which of the following observations should the nurse identify as the desired response to fluid replacement?
- A. Urine output 160 cc/8 h.
- B. Hgb 11 g, Hct 33%.
- C. Arterial pH 7.34.
- D. CVP reading of 8 cm of water pressure.
Correct Answer: D
Rationale: Strategy: Determine the significance of each answer choice and how it relates to hypovolemia. (1) indicates a hypovolemic state (2) indicates a hypovolemic state (3) indicates acidosis (4) correct-normal range for CVP is 3-8 cm water pressure (or 2-6 mm Hg); reading of 8 cm water pressure would indicate a desired response to fluid replacement
While giving care to a 2 year-old client, the nurse should remember that the toddler's tendency to say 'no' to almost everything is an indication of what psychosocial skill?
- A. Stubborn behavior
- B. Rejection of parents
- C. Frustration with adults
- D. Assertion of control
Correct Answer: D
Rationale: Assertion of control. Negativity is a normal behavior in toddlers. The nurse must be aware that this behavior is an important sign of the child's progress from dependency to autonomy and independence.