Nokea
The nurse has received the client assignment for the day. Which client should the nurse care for first?
- A. A client with a wound infection who has a temperature of 100.4°F
- B. A client with a deep vein thrombosis who reports bleeding gums when brushing the teeth
- C. A client who had a right arm casted 12 hours ago who is complaining of numbness in the fingers
- D. A client with chronic obstructive pulmonary disease (COPD) who has a respiratory rate of 22 beats per minute
Correct Answer: C
Rationale: The client with a cast who experiences numbness in the fingers should be seen first because this could be a symptom of compartment syndrome. Compartment syndrome creates an emergency situation when it does occur. Within 4 to 6 hours after the onset of compartment syndrome, neurovascular and muscle damage are irreversible if treatment is not provided. The limb can become useless in 24 to 48 hours. It would be expected that the client with a wound infection will have an elevation in body temperature. A client on anticoagulant therapy for treatment of a deep vein thrombosis who experiences bleeding gums when brushing teeth should be evaluated but is not the priority. A respiratory rate of 22 breaths per minute in the client with COPD is considered normal.
You may also like to solve these questions
The nurse is evaluating the effectiveness of antimicrobial therapy for a client diagnosed with infective endocarditis. The nurse determines that which finding is the least reliable indicator of effectiveness?
- A. Clear breath sounds
- B. Systolic heart murmur
- C. Temperature of 98.8°F
- D. Negative blood cultures
Correct Answer: B
Rationale: A systolic heart murmur, once present in the client, will not resolve spontaneously and is therefore the least reliable indicator. Clear breath sounds are a normal finding, and in this instance could mean resolution of heart failure, if that was accompanying the endocarditis. Negative blood cultures and normothermia indicate resolution of infection.
A client is receiving a transfusion of packed red blood cells. Which of the following actions should the nurse implement to safely administer the blood?
- A. Keep the blood refrigerated on the nursing unit until ready to administer.
- B. Stay with the client during the first 15 minutes to detect signs or symptoms of a reaction.
- C. Do not infuse blood that has been hanging for more than 6 hours.
- D. Administer the blood quickly to prevent wasting it if the client develops a fever.
Correct Answer: B
Rationale: Staying with the client for the first 15 minutes is critical to monitor for acute transfusion reactions, which are most likely to occur early.
The nurse is caring for a client with bipolar disorder in a manic phase. Which intervention is most appropriate?
- A. Encourage group activities.
- B. Provide a quiet environment.
- C. Allow unlimited phone calls.
- D. Offer high-calorie snacks.
Correct Answer: B
Rationale: A quiet environment reduces stimuli, helping to calm a client in a manic phase.
A client with a history of rheumatoid arthritis is prescribed methotrexate. The nurse should monitor the client for which of the following adverse effects?
- A. Hepatotoxicity.
- B. Hyperkalemia.
- C. Hypotension.
- D. Weight gain.
Correct Answer: A
Rationale: Methotrexate can cause hepatotoxicity, requiring regular liver function tests.
A client with a history of type 2 diabetes is prescribed sitagliptin (Januvia). The nurse should instruct the client to:
- A. Take the medication with meals.
- B. Monitor for signs of pancreatitis.
- C. Take the medication at bedtime.
- D. Stop the medication if blood glucose normalizes.
Correct Answer: B
Rationale: Sitagliptin can cause pancreatitis, requiring monitoring for abdominal pain.