Nokea
The nurse is arriving at the beginning of her shift and has taken report on four clients on a medical-surgical unit. Which client should the nurse see first?
- A. A client with pain that is two days post-operative from a prostatectomy
- B. A client ready for discharge education after treatment of an acute kidney injury
- C. A client with hypertension with a blood pressure of 172/92 mm Hg
- D. A client with a history of asthma complaining of increased dyspnea
Correct Answer: D
Rationale: Asthma's increased dyspnea flags airway risk ABCs prioritize breathing, as bronchospasm could crash fast, needing nebulizers or oxygen. Post-op pain's manageable, discharge education waits, hypertension's high but stable. Nurses hit dyspnea first, ensuring airflow, a life-first call in this shift-start triage.
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During hourly rounding the nurse enters a room where the client is unresponsive without pulse. What is the nurse's priority action?
- A. Begin ventilation at 1 breath every 6-8 seconds
- B. Start chest compressions at a rate of 100-120 compressions per minute
- C. Wait for the emergency response team for direction
- D. Call the family
Correct Answer: B
Rationale: No pulse, no response cardiac arrest kicks in chest compressions, 100-120/min, pumping life per ACLS, trumping breaths first in lone-rescuer mode. Waiting or calling delays; ventilation follows. Nurses hammer compressions, buying brain time, a priority slam in this code blue crash.
Regarding HIV/AIDS
- A. Shingles, seborrhoeic dermatitis and recurrent HSV infections are typical of early infection
- B. A CD4 count of 1.0 x 10^9/L is associated with late stage AIDS
- C. Pre and post test counselling for HIV serology is now no longer mandatory
- D. Pneumococcus is a more likely pathogen than TB in AIDS patients with pneumonia
Correct Answer: D
Rationale: HIV early skin woes, CD4's units flop, counseling holds, TB trumps pneumococcus, toxo hits brain. Nurses chase this chronic lung truth.
The hospice nurse is caring for a patient with cancer in her home. The nurse has explained to the patient and the family that the patient is at risk for hypercalcemia and has educated them on that signs and symptoms of this health problem. What else should the nurse teach this patient and family to do to reduce the patient's risk of hypercalcemia?
- A. Stool softeners are contraindicated
- B. Laxatives should be taken daily
- C. Consume 2 to 4 L of fluid daily
- D. Restrict calcium intake
Correct Answer: C
Rationale: Hypercalcemia cancer's bone breakdown gift needs hydration (2-4 L/day) to flush calcium through kidneys, unless heart or renal issues say no. Stool softeners and laxatives fight constipation (a symptom), not the cause, and aren't contraindicated. Cutting calcium's pointless tumors, not diet, spike it. Nurses in hospice drill this, balancing fluid push with symptom watch (confusion, thirst), keeping comfort king in late-stage oncology care.
A client diagnosed with stable angina is complaining of substernal chest pain, rating the pain 5 out of 10. What would be the priority action by the nurse?
- A. Administer the client's prescribed beta-blocker
- B. Administer nitroglycerin intravenously immediately
- C. Administer morphine
- D. Administer 325 mg of chewable aspirin immediately
Correct Answer: D
Rationale: Stable angina's oxygen pinch 5/10 pain bows to aspirin's antiplatelet punch, cutting clot risk fast, a priority over beta-blockers' slow rate drop. IV nitroglycerin's for MI, morphine's overkill, aspirin's chewed for quick absorption. Nurses hit this, easing ischemia, a front-line move in this chest squeeze.
A patient with metastatic cancer of the colon experiences severe vomiting after each administration of chemotherapy. Which action, if taken by the nurse, is appropriate?
- A. Have the patient eat large meals when nausea is not present.
- B. Offer dry crackers and carbonated fluids during chemotherapy.
- C. Administer prescribed antiemetics 1 hour before the treatments.
- D. Give the patient a glass of a citrus fruit beverage during treatments.
Correct Answer: C
Rationale: Chemo vomiting's a beast pre-dosing antiemetics (e.g., ondansetron) an hour before blocks the gut-brain puke loop, the gold standard. Big meals overload; crackers and soda or citrus during treatment spark nausea acidity and fizz don't help. Nurses in oncology time this right prevention trumps mopping up, keeping patients steady.