Nokea
The nurse has just received a report from the previous shift. Which of the following clients should the nurse visit first?
- A. A 50-year-old COPD client with a PCO2 of 50
- B. A 24-year-old admitted after an MVA complaining of shortness of breath
- C. A client with cancer requesting pain medication
- D. A 1-day post-operative cholecystectomy with a temperature of 100°F
Correct Answer: B
Rationale: Shortness of breath post-MVA suggests potential trauma (e.g., pneumothorax), requiring immediate assessment. The other clients' conditions are less acute.
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The client with a recent liver transplant asks the nurse how long he will have to take an immunosuppressant. Which response would be correct?
- A. 1 year
- B. 5 years
- C. 10 years
- D. The rest of his life
Correct Answer: D
Rationale: Lifelong immunosuppression is required post-transplant to prevent organ rejection.
A woman is receiving outpatient treatment at a mental health center. She starts crying and tells the nurse her husband has filed for divorce. The best response from the nurse is
- A. I am so sorry. I am divorced too, but it worked out for the best.'
- B. About half of marriages end in divorce these days.'
- C. You have to let him go and move on with your life.'
- D. Tell me what happened.'
Correct Answer: D
Rationale: An open-ended response like 'Tell me what happened' encourages the client to express feelings, fostering therapeutic communication.
A client diagnosed with tuberculosis asks the nurse when he can return to work. The nurse should tell the client that:
- A. He can return to work when he has three negative sputum cultures.
- B. He can return to work as soon as he feels well enough.
- C. He can return to work after a week of being on the medication.
- D. He should think about applying for disability because he will no longer be able to work.
Correct Answer: A
Rationale: Three negative sputum cultures indicate the client is no longer contagious, allowing safe return to work after tuberculosis treatment.
A client is admitted for an CAT scan. The nurse should question the client regarding:
- A. Pregnancy
- B. A titanium hip replacement
- C. Allergies to antibiotics
- D. Inability to move his feet
Correct Answer: A
Rationale: Pregnancy is a contraindication for a CAT scan due to radiation risks to the fetus.
A Turkish-speaking client is scheduled for a colonoscopy, and the nurse must provide printed directions to the client, but directions are not available in Turkish. Which of the following is most appropriate?
- A. The nurse contacts a medical translator to translate.
- B. The client's 10-year-old daughter translates the directions.
- C. The nurse draws pictures and pantomimes directions.
- D. Client's daughter is advised to tell her parent to seek a translator.
Correct Answer: A
Rationale: Contacting a medical translator (A) ensures accurate communication for critical medical instructions. Using a child (B) is unreliable, pictures/pantomime (C) may be unclear, and advising the daughter to find a translator (D) shifts responsibility inappropriately.