Nokea
The nurse is assessing a client with suspected hypovolemic shock. Which finding is most indicative?
- A. Tachycardia
- B. Hypertension
- C. Warm, dry skin
- D. Bradypnea
Correct Answer: A
Rationale: Tachycardia is an early sign of hypovolemic shock as the body compensates for reduced blood volume by increasing heart rate.
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A client with diabetes is explaining to the nurse how she will care for her feet at home. Which statement indicates that the client understands proper foot care?
- A. When I injure my toe, I will plan to put iodine on it.'
- B. I should inspect my feet at least once a week.'
- C. It is okay to go barefoot in the house.'
- D. It is important to dry my feet carefully after my bath.'
Correct Answer: D
Rationale: Thorough drying prevents moisture-related infections, critical for diabetic foot care to avoid complications like ulcers.
A client is admitted with a suspected myocardial infarction. The nurse should prioritize which of the following interventions?
- A. Administer aspirin as ordered.
- B. Obtain a 12-lead ECG.
- C. Insert an I.V. line.
- D. Administer morphine for pain.
Correct Answer: B
Rationale: Obtaining a 12-lead ECG is the priority to confirm myocardial infarction and guide treatment.
The nurse should instruct the parents of a school-age child with hemophilia to implement which of the following when the child develops bleeding into a joint? Select all that apply.
- A. Having the child rest
- B. Applying heat to the joint area
- C. Beginning factor VIII therapy
- D. Starting physical therapy
- E. Applying a topical antifibrinolytic
Correct Answer: A,C
Rationale: Resting the joint and administering factor VIII therapy are critical to manage bleeding in hemophilia. Heat and physical therapy may worsen bleeding, and topical antifibrinolytics are not effective for joint bleeds.
A Jewish client requests an orthodox diet while she is hospitalized. The nurse should refer this request to the:
- A. Dietitian
- B. Physician
- C. Unit case manager
- D. Rabbi in pastoral care
Correct Answer: A
Rationale: The dietitian is responsible for addressing dietary requests, including religious preferences like an orthodox Jewish diet, to ensure nutritional needs are met. The physician, case manager, or rabbi may not specialize in dietary planning.
The nurse is caring for a client who is having an acute asthma attack. The nurse should notify the physician of which of the following?
- A. Loud wheezing.
- B. Tenacious, thick sputum.
- C. Decreased breath sounds.
- D. Persistent cough.
Correct Answer: C
Rationale: Decreased breath sounds indicate severe airway obstruction in an asthma attack, requiring immediate physician notification.