Nokea
The nurse has been made aware of the following client situations. The nurse should first assess the client who has
- A. bacterial meningitis and is receiving a third dose of intravenous doxycycline and reports a rash on their torso.
- B. a cerebral aneurysm and is nervous about their scheduled surgery in one hour.
- C. amyotrophic lateral sclerosis (ALS) and coughs when attempting to eat and drink.
- D. a migraine headache and has developed flushing after receiving prescribed intranasal sumatriptan.
Correct Answer: A
Rationale: A rash during doxycycline for meningitis (A) suggests a possible allergic reaction, a life-threatening complication requiring immediate assessment. Pre-surgical anxiety (B), ALS coughing (C), and sumatriptan flushing (D) are less acute, as they are expected or stable.
You may also like to solve these questions
The emergency department (ED) is caring for a client with a pulse (P) of 42, blood pressure (BP) of 90/60 mm Hg, and reports dizziness. Which of the following actions is the priority?
- A. Obtain an order for a chest radiograph (x-ray)
- B. Review the client's current medications
- C. Perform a focused neurological assessment
- D. Obtain a 12-lead electrocardiogram (ECG)
Correct Answer: D
Rationale: A pulse of 42 with hypotension and dizziness (D) suggests symptomatic bradycardia, requiring an immediate ECG to identify arrhythmias, per ACLS guidelines. Chest x-ray (A), medication review (B), and neurological assessment (C) are secondary to cardiac evaluation.
The medical-surgical nurse is preparing for the admission of an older adult following a ground-level fall. The nurse should prioritize teaching the client
- A. how to use the telephone and order meals.
- B. their prescribed medications for the shift.
- C. the prescribed pain management plan.
- D. how to operate the call light.
Correct Answer: D
Rationale: Teaching how to operate the call light (D) is the priority to ensure the client can request assistance, preventing falls and ensuring safety. Telephone use (A), medications (B), and pain management (C) are important but secondary to immediate safety needs.
The nurse knows that the concept of management is most closely associated with:
- A. Decision-making, problem-solving, and priority setting.
- B. Inspirational abilities and coaching.
- C. Visionary abilities and supervision.
- D. Motivational and visionary abilities.
Correct Answer: A
Rationale: Management is closely associated with decision-making, problem-solving, and priority setting (A), which are core functions of organizing and coordinating care. Inspirational (B), visionary (C), and motivational (D) abilities align more with leadership than management.
The nursing student inserts an indwelling urinary catheter for a female patient prior to surgery. Which of the following would require immediate intervention by the RN?
- A. The patient states she feels the need to urinate.
- B. Patient reports a pinching sensation as the catheter is advanced.
- C. The student nurse notes resistance when inflating the balloon.
- D. The student separates the labia majora and labia minora with non-dominant hand.
Correct Answer: C
Rationale: Resistance when inflating the catheter balloon (C) suggests improper placement (e.g., in urethra), risking trauma, requiring immediate RN intervention. Urge to urinate (A) and pinching (B) are normal, and labia separation (D) is correct technique.
“ Initiate intravenous fluids to a client with anorexia nervosa
Administer venlafaxine to a client with persistent depressive disorder
Consult the social worker to begin discharge planning for a client
Obtain a blood sample to evaluate a client's lithium level”
The nurse has received the following prescriptions for newly admitted clients. The nurse should initially implement which of the following?
- A. initiate intravenous fluids to a client with anorexia nervosa.
- B. administer venlafaxine to a client with persistent depressive disorder.
- C. consult the social worker to begin discharge planning for a client.
- D. obtain a blood sample to evaluate a client's lithium level.
Correct Answer: A
Rationale: Initiating IV fluids for anorexia nervosa (A) is the priority to address life-threatening dehydration and electrolyte imbalances. Administering venlafaxine (B), consulting a social worker (C), and obtaining a lithium level (D) are less urgent, as they do not address immediate physiological threats.