Nokea
The nurse has received the following information about assigned clients. The nurse should initially assess the client who is at
- A. 15 weeks gestation who reports not feeling any fetal movement.
- B. 28 weeks gestation who reports swollen feet and ankles.
- C. 36 weeks gestation who reports contractions that are irregular.
- D. 37 weeks gestation experiencing variable decelerations.
Correct Answer: D
Rationale: Variable decelerations at 37 weeks (D) indicate possible umbilical cord compression, a fetal emergency requiring immediate assessment. No fetal movement at 15 weeks (A) is normal, edema at 28 weeks (B) is common, and irregular contractions at 36 weeks (C) are non-urgent.
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The nurse is caring for the following assigned clients. It would be a priority to follow up with a client who
- A. is being treated for acute glomerulonephritis (AGN) and has periorbital edema.
- B. has urolithiasis and reports persistent nausea.
- C. is receiving continuous bladder irrigation and reports the need to void.
- D. just returned from a hemodialysis session and reports dizziness.
Correct Answer: D
Rationale: Dizziness post-hemodialysis (D) suggests hypotension or fluid shifts, a life-threatening complication requiring immediate follow-up. Edema in AGN (A), nausea with urolithiasis (B), and voiding sensation with irrigation (C) are less urgent.
The nurse has been made aware of the following client situations. The nurse should first follow up with the client
- A. receiving a chemotherapy infusion who reports nausea and vomiting.
- B. newly diagnosed with polycystic kidney disease reporting hematuria and flank pain.
- C. being treated for aplastic anemia and has a temperature of 101.1°F (38.4°C).
- D. being treated for pulmonary tuberculosis and ambulating in the hallway wearing a surgical mask.
Correct Answer: C
Rationale: A fever in a client with aplastic anemia (C) indicates potential infection, a life-threatening complication due to low white blood cells, requiring immediate attention. Nausea from chemotherapy (A), hematuria with kidney disease (B), and TB with a mask (D) are less urgent.
The nurse is caring for a client with diabetic ketoacidosis and is prescribed a bolus of regular insulin followed by a continuous infusion of regular insulin. Prior to starting the continuous infusion, the nurse administers 1 unit/kg of regular insulin to the client instead of the 0.1 unit/kg bolus. The nurse should take which initial action?
- A. Notify the primary healthcare provider (PHCP)
- B. Complete an incident report
- C. Assess the client for hypoglycemia
- D. Withhold the insulin infusion
Correct Answer: C
Rationale: Administering a 10-fold insulin overdose (C) risks severe hypoglycemia, so assessing the client immediately is critical to detect and treat low glucose. Notifying the PHCP (A), reporting (B), and withholding infusion (D) follow but are less urgent than client assessment.
After talking to a her family, an elderly client says that she wants to change their living will she wrote two weeks ago. The nurse's most appropriate reply would be:
- A. You can only change your living will a year after it is formulated.
- B. Let me see if I can find someone to help you.
- C. You cannot only make changes to your will after 3 weeks.
- D. Let's call your lawyer first and see what he thinks they think.
Correct Answer: B
Rationale: The nurse should assist the client by finding someone to help (B), such as a social worker or legal resource, to facilitate changes to the living will. There are no time restrictions (A, C), and contacting a lawyer (D) is unnecessary unless requested by the client.
You are caring for a 33-year-old male client at the end of life. This married client has two children; the son is 14-years-old and the daughter is 8-years-old. Both of these children are being prepared for their father's imminent death. Which consideration should be incorporated into your explanations of death with these children?
- A. Children before the age of 12 view death as terrifying so the nurse should not discuss death with these young children.
- B. Children before the age of 12 do not have any perspectives about death, its meaning, and its finality or lack thereof.
- C. The cognitive development of young children impacts their understanding of death.
- D. The cognitive development of young children before 12 has no impact on their understanding of death
Correct Answer: C
Rationale: Cognitive development (C) influences how children, like the 8-year-old, understand death. Younger children may view death as reversible or temporary, while adolescents, like the 14-year-old, grasp its finality. Tailoring explanations to their developmental stage is essential. Options A and B are incorrect as children do have perspectives, and avoiding discussion (A) is unhelpful. Option D contradicts developmental psychology.