Nokea
The nurse is assessing a client with a suspected cholecystitis. Which of the following findings is most indicative of this condition?
- A. Right upper quadrant pain.
- B. Left lower quadrant pain.
- C. Soft, nontender abdomen.
- D. Frequent loose stools.
Correct Answer: A
Rationale: Right upper quadrant pain is a hallmark sign of cholecystitis due to gallbladder inflammation.
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Which of the following actions by the nurse will most likely ensure that the correct client receives a medication? Select all that apply.
- A. Have the client state his or her name.
- B. Check the name on the arm band with the name on the medication.
- C. Learn to recognize the client.
- D. Check the client's room number.
- E. Compare the date of birth on the client's chart to the date of birth on the client's armband.
Correct Answer: A,B,E
Rationale: Using two identifiers, such as the client's name, armband, and date of birth, ensures accurate medication administration. Room number and visual recognition are not reliable.
A client with a history of bipolar disorder is prescribed lithium. The nurse should instruct the client to:
- A. Maintain a consistent sodium intake.
- B. Avoid drinking coffee.
- C. Take the medication with meals.
- D. Stop the medication if tremors occur.
Correct Answer: A
Rationale: Consistent sodium intake prevents lithium toxicity, as sodium fluctuations affect lithium levels.
A nurse is planning care for a 7-year-old who is hospitalized for a hernia repair. The nurse should assess the client for which of the following fears common in this age group?
- A. Separation from parents.
- B. Trying something new.
- C. Injury and pain.
- D. Opposite-sex relationships.
Correct Answer: C
Rationale: School-age children (7 years) commonly fear injury and pain, especially in medical settings, due to their growing awareness of bodily harm.
The nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions is the highest priority to prevent ventilator-associated pneumonia?
- A. Performing oral care every 4 hours.
- B. Elevating the head of the bed to 30-45 degrees.
- C. Administering prophylactic antibiotics.
- D. Suctioning the endotracheal tube every 2 hours.
Correct Answer: B
Rationale: Elevating the head of the bed to 30-45 degrees reduces the risk of aspiration, a key factor in preventing ventilator-associated pneumonia.
The nurse is caring for a client who has been diagnosed with deep vein thrombosis. When assessing the client's vital signs, the nurse notes an apical pulse of 150 bpm, a respiratory rate of 46 breaths/minutes, and blood pressure of 100/60 mm Hg. The client appears anxious and restless. What should be the nurse's first course of action?
- A. Notify the physician.
- B. Administer a sedative.
- C. Try to elicit a positive Homan's sign.
- D. Increase the flow rate of intravenous fluids.
Correct Answer: A
Rationale: These symptoms suggest a possible pulmonary embolism, a life-threatening complication of DVT, requiring immediate physician notification.