Nokea
The nurse has assigned a nursing assistant to give the client a bath. Which observation reported by the nursing assistant requires immediate attention by the nurse?
- A. A red area on the back that disappears after it is massaged
- B. A red area on the hip that does not go away after the area is massaged
- C. The client's insistence on doing most of the bath
- D. The indwelling urethral catheter is draining clear, amber urine.
Correct Answer: B
Rationale: A non-blanching red area on the hip suggests a pressure injury, requiring immediate nursing intervention to prevent progression.
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The nurse is caring for a client with cirrhosis who has ascites, peripheral edema, shortness of breath, fatigue, and generalized discomfort. Which of the following actions should the nurse take? Select all that apply.
- A. Assist the client to ambulate in the hallway every shift
- B. Encourage the client to increase sodium intake
- C. Maintain the client in semi-Fowler position
- D. Provide an alternating air pressure mattress for the client
- E. Use music to provide a distraction for the client
Correct Answer: C,D,E
Rationale: Semi-Fowler position helps alleviate shortness of breath by reducing pressure on the diaphragm. An alternating air pressure mattress reduces the risk of pressure injuries due to immobility. Music can help reduce discomfort and anxiety, providing a non-pharmacological distraction.
The nurse is caring for a client with extracellular fluid volume deficit. Which of the following assessments would the nurse anticipate finding?
- A. bounding pulse
- B. rapid respirations
- C. oliguria
- D. neck veins are distended
Correct Answer: C
Rationale: oliguria. Kidneys maintain fluid volume through adjustments in urine volume.
The nurse is screening clients with major depressive disorder for those at risk for suicide. The nurse should recognize the client at highest risk for suicide is the client with
- A. substance use disorder who is married and participates in community programs
- B. Parkinson disease who is divorced and has recently become unemployed
- C. breast cancer who is married and is newly diagnosed with alcohol use disorder
- D. type 2 diabetes mellitus who is recently divorced and has 3 children
Correct Answer: B
Rationale: Recent unemployment and divorce are significant stressors that increase suicide risk, especially in a client with a chronic condition like Parkinson disease, which can exacerbate depressive symptoms.
The nurse on the telemetry unit is preparing client medications in the medication room. Which of the following actions should the nurse perform to be consistent with client safety practices related to medication administration? Select all that apply.
- A. Confirm the client's identity, medication, dosage, time, and route prior to medication administration
- B. Do not administer any medication that is damaged or has an unreadable label
- C. Place all medications in a dispensing cup before taking them to a client's room
- D. Review laboratory values before administering anticoagulants
- E. Wear gloves when handling transdermal medication patches
Correct Answer: A,B,D,E
Rationale: These actions align with safe medication administration practices: verifying the 'five rights' (A), ensuring medication integrity (B), checking relevant lab values for anticoagulants (D), and using gloves to prevent absorption of transdermal medications (E).
A client was struck on the head by a baseball bat during a robbery attempt. The nurse gives shift report to the oncoming nurse and conveys that the client's current Glasgow Coma Scale score is a '10.' Which other information is most important for the reporting nurse to include?
- A. Client's blood pressure was 120/80 mm Hg and pulse was 82/min recently
- B. Client's Glasgow Coma Scale score was '11' one hour ago
- C. Client believes that the current surroundings are a racetrack
- D. Client is allergic to penicillin and vancomycin
Correct Answer: B
Rationale: A decrease in Glasgow Coma Scale score from 11 to 10 in one hour indicates worsening neurological status, possibly due to increasing intracranial pressure, requiring urgent reporting.