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The nurse has received her assignment for the day and is to care for the following clients. Which client should the nurse go to first?
- A. A 56-year-old who was admitted last evening vomiting blood; the night nurse says he has had no emesis for the last four hours
- B. A 65-year-old who had hip replacement surgery two days ago
- C. A 68-year-old who fell yesterday and is scheduled for hip surgery later this morning
- D. A 69-year-old who was admitted last evening with severe right upper quadrant and right scapular pain
Correct Answer: A
Rationale: The client with recent hematemesis is at risk for recurrent bleeding, requiring immediate assessment to ensure stability, prioritizing over stable surgical or presurgical clients.
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An elderly client is admitted to a skilled nursing care facility. When doing a skin assessment, the nurse notes a 3-cm round area of partial-thickness skin loss that looks like a blister on the client's sacrum. The nurse interprets this to be a:
- A. stage I pressure ulcer.
- B. stage II pressure ulcer.
- C. stage III pressure ulcer.
- D. stage IV pressure ulcer.
Correct Answer: B
Rationale: A stage II pressure ulcer involves partial-thickness skin loss, often presenting as a blister or shallow open ulcer, matching the description. Stage I is non-blanchable erythema, stage III involves full-thickness loss, and stage IV extends to muscle/bone.
The nurse is caring for a client with a history of type 1 diabetes who is receiving insulin lispro (Humalog) 8 units before meals. Which of the following symptoms should the nurse report immediately?
- A. Mild fatigue.
- B. Sweating and confusion.
- C. Occasional thirst.
- D. Mild headache.
Correct Answer: B
Rationale: Sweating and confusion indicate hypoglycemia, a medical emergency with insulin lispro. Options A, C, and D are less urgent.
Which of the following should the nurse implement to prepare a client for a kidney, ureter, bladder (KUB) radiograph test?
- A. Client must be NPO before the examination
- B. Enema to be administered prior to the examination
- C. Medicate client with Lasix 20 mg IV 30 minutes prior to the examination
- D. No special orders are necessary for this examination
Correct Answer: D
Rationale: No special orders are necessary for this examination. No special preparation is necessary for this examination.
An elderly client is oriented during the day but becomes disoriented during the evening.
Which of the following nursing actions is MOST appropriate?
- A. Place a clock where the client can see it.
- B. Restrain all four extremities.
- C. Keep a light on in the client's room.
- D. Place the side rails in an upright position.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will provide visual cues, safety is more important (2) inappropriate (3) may be appropriate, but is not priority over answer choice #4 (4) correct-side rails should always be in an upright position for a disoriented client
A Hispanic client in the postpartum period refuses the hospital food because it is 'cold.' The best initial action by the nurse is to
- A. Have the unlicensed assistive personnel (UAP) reheat the food if the client wishes
- B. Ask the client what foods are acceptable or are unacceptable
- C. Encourage her to eat for healing and strength
- D. Schedule the dietitian to meet with the client as soon as possible
Correct Answer: B
Rationale: Ask the client what foods are acceptable or are unacceptable. Understanding cultural food preferences ensures appropriate dietary support.