Nokea
The nurse has just returned to the desk and has four phone messages to return. Which of the following messages should the nurse return FIRST?
- A. A woman in her first trimester of pregnancy complaining of heartburn.
- B. A man complaining of heartburn that radiates to his jaw.
- C. A woman complaining of hot flashes and difficulty sleeping.
- D. A boy complaining of knee pain after playing basketball.
Correct Answer: B
Rationale: indicates chest pain, needs to seek medical attention immediately
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A client is to receive 1,000 mL of potassium chloride in 5% dextrose injection (D5W) intravenously over 3 hours and 20 minutes using a drop factor of 15 drops/mL. What is the required flow rate (drops) per minute? Record your answer using a whole number.
Correct Answer: 75
Rationale: To calculate the flow rate in drops per minute, use the formula: (Total volume X Drop factor)/ Total time in minutes. The total volume is 1,000 mL, the drop factor is 15 drops/mL, and the time is 3 hours 20 minutes = 200 minutes. Thus, (1,000 X 15)/ 200 = 15,000/ 200 = 75 drops/minute.
When determining whether or not a client is a candidate for restraints, which of the following would be considered an appropriate reason for a restraint?
- A. Current dangerous behavior
- B. History of falls
- C. Recent violent attack on a staff member
- D. Refusal to cooperate with treatment
Correct Answer: A
Rationale: Restraints are justified for current dangerous behavior (A) posing immediate risk to self or others. History of falls (B), past violence (C), or non-cooperation (D) do not warrant restraints.
Which statement is true regarding balanced skeletal traction? Balanced skeletal traction:
- A. Utilizes a Steinman pin
- B. Requires that both legs be secured
- C. Utilizes Kirschner wires
- D. Is used primarily to heal the fractured hips
Correct Answer: A
Rationale: Balanced skeletal traction commonly uses a Steinman pin to stabilize fractures.
A client visits the clinic after the death of a parent. Which statement made by the client's sister signifies abnormal grieving?
- A. My sister still has episodes of crying, and it's been three months since Daddy died.
- B. Sally seems to have forgotten the bad things that Daddy did in his lifetime.
- C. She really had a hard time after Daddy's funeral. She said that she had a sense of longing.
- D. She has not been saddened at all by Daddy's death. She acts like nothing has happened.
Correct Answer: D
Rationale: Denial of grief, as indicated by acting like nothing has happened, suggests abnormal grieving, as it may reflect an inability to process the loss.
The home health nurse is planning for the day's visits. Which client should be seen first?
- A. The 78-year-old who had a gastrectomy 3 weeks ago and has a PEG tube
- B. The 5-month-old discharged 1 week ago with pneumonia who is being treated with amoxicillin liquid suspension
- C. The 50-year-old with MRSA being treated with Vancomycin via a PICC line
- D. The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter
Correct Answer: B
Rationale: The 5-month-old with recent pneumonia is at high risk for complications, prioritizing their assessment.