Nokea
The nurse has reported to the hospital to work the evening shift on a respiratory unit. The nurse's assignment consists of four clients. Prioritize in order from highest to lowest priority how the nurse would assess the clients after receiving report.
- A. An 85-year-old client with bacterial pneumonia, temperature of 102.2°F (42°C), and shortness of breath.
- B. A 60-year-old client with chest tubes who is 2 days postoperative following a thoracotomy for lung cancer and is requesting something for pain.
- C. A 35-year-old client with suspected tuberculosis who is complaining of a cough.
- D. A 56-year-old client with emphysema who has a scheduled dose of a bronchodilator due to be administered, with no report of acute respiratory distress.
Correct Answer: A,B,C,D
Rationale: The client with pneumonia, fever, and shortness of breath is at highest risk for respiratory compromise (A). The postoperative client with pain (B) is next due to pain's impact on breathing. The client with suspected tuberculosis and cough (C) is lower priority but needs isolation precautions. The client with emphysema awaiting a scheduled bronchodilator (D) is stable.
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The nurse is assessing the client's use of medications. Which of the following medications may cause a complication with the treatment plan of a client with diabetes?
- A. Aspirin.
- B. Steroids.
- C. Sulfonylureas.
- D. Angiotensin-converting enzyme (ACE) inhibitors.
Correct Answer: B
Rationale: Steroids can increase blood glucose levels, complicating diabetes management by causing hyperglycemia.
The nurse is assessing a 42-year-old client with cancer. He has lost 1 lb in 4 weeks. He is taking ondansetron (Zofran) for nausea. He has a temperature of 101°F (38.3°C). The fever is indicative of:
- A. Inadequate nutrition.
- B. New resistance to current antiemetic therapy.
- C. Expected response to chemotherapy treatment.
- D. Infection.
Correct Answer: D
Rationale: A fever of 101°F in a cancer patient, especially during chemotherapy, is most likely indicative of infection, which requires prompt evaluation due to immunosuppression.
Which client position is contraindicated for a client with a spinal cord injury?
- A. Supine with head flat.
- B. Logrolling technique.
- C. Head elevated 30 degrees.
- D. Neutral neck alignment.
Correct Answer: A
Rationale: Supine with head flat is contraindicated as it may increase spinal pressure; other positions support alignment and safety.
A nurse is obtaining consent for a bone marrow aspiration. What should the nurse do? Select all that apply.
- A. Witness the client signing the consent form.
- B. Evaluate that the client understands the procedure.
- C. Explain the risks of the procedure to the client.
- D. Verify that the client is signing the consent form of his own free will.
- E. Determine that the client understands postprocedure care.
Correct Answer: A,B,D,E
Rationale: The nurse's role in obtaining consent includes witnessing the signature, ensuring the client understands the procedure and postprocedure care, and verifying voluntary consent. Explaining risks is typically the physician's responsibility.
Which of the following exercises should the nurse advise the client to avoid after a lumbar laminectomy?
- A. Knee-to-chest lifts.
- B. Hip tilts.
- C. Sit-ups.
- D. Pelvic tilts.
Correct Answer: C
Rationale: Sit-ups strain the surgical site and should be avoided to prevent injury post-laminectomy.