Nokea
The nurse is assessing a client with a closed reduction of a fractured femur. Which finding should the nurse report to the physician?
- A. Chest pain and shortness of breath.
- B. Ecchymosis on the side of the injured leg.
- C. Oral temperature of 99.2°F.
- D. Complaints of level two pain on a scale of five.
Correct Answer: A
Rationale: Chest pain and shortness of breath may indicate a pulmonary embolism, a serious complication requiring immediate reporting.
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A client has been receiving cyanocobalamine (B12) injections for the past six weeks. Which laboratory finding indicates that the medication is having the desired effect?
- A. Neutrophil count of 60%
- B. Basophil count of 0.5%
- C. Monocyte count of 2%
- D. Reticulocyte count of 1%
Correct Answer: D
Rationale: Increased reticulocyte count indicates effective B12 therapy for anemia.
A client is receiving end-of-life care and tells the nurse that he has not always lived the way he should have or treated his children well. Which of the following responses is the most appropriate?
- A. What kinds of things have you done?'
- B. There are things that you regret.'
- C. I'm sure those things don't matter anymore.'
- D. It's not too late to ask for forgiveness.'
Correct Answer: B
Rationale: Reflecting that the client has regrets (B) is empathetic and opens further discussion without judgment. Asking for details (A), dismissing concerns (C), or suggesting forgiveness (D) may not be appropriate.
A 19-year-old male was prescribed sertraline (Zoloft) 3 weeks ago for depression. He calls the clinic today and tells the nurse that he has been feeling increasingly anxious and wants to stop taking the medication because it is not working. The best response for the nurse is
- A. You can stop taking the Zoloft, but let's make another appointment with your provider so you can try a different medication.'
- B. Increased anxiety is a normal side effect for the first few weeks of taking this medication. It will take several weeks to determine if it is working. Please keep taking it as prescribed.'
- C. Increased anxiety is not a normal side effect of Zoloft. What day this week can you come to the clinic to discuss this with your provider?'
- D. Try taking half the prescribed dose for the next week and see if that helps the feelings of anxiety.'
Correct Answer: B
Rationale: Increased anxiety is a common early side effect of SSRIs like sertraline, which typically subsides after a few weeks. The therapeutic effect takes 4-6 weeks. Continuing the medication and monitoring is appropriate.
The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respirations 30. Which action by the nurse should receive priority?
- A. Document the finding.
- B. Contact the physician.
- C. Elevate the head of the bed.
- D. Administer a pain medication.
Correct Answer: B
Rationale: The vital signs indicate shock, so contacting the physician for immediate intervention is the priority.
A client has suffered a severe electrical burn. Which medication would the nurse expect to have ordered for application to the burned area?
- A. Mafenide acetate (Sulfamylon)
- B. Silver nitrate
- C. Providone-iodine ointment
- D. Silver sulfadiazine (Silvadene)
Correct Answer: D
Rationale: Silver sulfadiazine (Silvadene) is commonly used for electrical burns due to its broad-spectrum antimicrobial properties and soothing effect on burn wounds.