Nokea
The nurse has just received the change of shift report and is preparing to make rounds. Which client should the nurse assess first?
- A. A client recovering from a stroke with an oxygen saturation rate of 99%
- B. A client three days post-coronary artery bypass graft with an oral temperature of 100.2°F
- C. A client admitted one hour ago with rales and shortness of breath
- D. A client being prepared for discharge following a right colectomy
Correct Answer: C
Rationale: The client admitted one hour ago with rales and shortness of breath indicates potential acute respiratory distress, possibly from pulmonary edema or pneumonia, requiring immediate assessment. The other clients are stable or less urgent.
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A nurse is performing a vaginal exam on a client in active labor. An important landmark to assess during labor and delivery are the ischial spines because:
- A. Ischial spines are the narrowest diameter of the pelvis
- B. Ischial spines are the widest diameter of the pelvis
- C. They represent the inlet of birth canal
- D. They measure pelvic floor
Correct Answer: A
Rationale: The ischial spines mark the narrowest diameter of the pelvis, critical for assessing fetal descent during labor.
A client with a history of seizure disorder is admitted with complaints of breakthrough seizures. The nurse should give priority to:
- A. Administering anticonvulsants
- B. Monitoring blood pressure
- C. Administering pain medication
- D. Monitoring respiratory rate
Correct Answer: A
Rationale: Administering anticonvulsants is the priority to control breakthrough seizures and prevent status epilepticus.
The nurse is performing an assessment on a client with a history of a tension pneumothorax. Which finding is most concerning?
- A. Tracheal deviation
- B. Chest pain
- C. Tachypnea
- D. Fever
Correct Answer: A
Rationale: Tracheal deviation in a tension pneumothorax indicates mediastinal shift from increased intrathoracic pressure, a life-threatening emergency requiring immediate attention.
A chronic alcoholic client's condition deteriorates, and he begins to exhibit signs of hepatic coma. Which of the following is an early sign of impending hepatic coma?
- A. Hiccups
- B. Anorexia
- C. Mental confusion
- D. Fetor hepaticus
Correct Answer: C
Rationale: One of the earliest symptoms of hepatic coma is mental confusion. Asterixis, a flapping tremor of the hand, may also be seen.
A client with a history of liver failure is admitted with complaints of confusion. The nurse should expect the client to have:
- A. Hyperammonemia
- B. Hypoglycemia
- C. Hypercalcemia
- D. Hypokalemia
Correct Answer: A
Rationale: Liver failure impairs ammonia detoxification, leading to hyperammonemia, which causes hepatic encephalopathy and confusion.