Nokea
The nurse is assessing a client with suspected meningitis. Which of the following findings would the nurse expect?
- A. Positive Kernig’s sign.
- B. Hypothermia.
- C. Soft, non-tender neck.
- D. Decreased level of consciousness.
Correct Answer: A
Rationale: positive Kernig’s sign (pain and resistance on leg extension) is a classic finding in meningitis
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The nurse is assessing a client for tactile fremitus. Which client would most likely exhibit a decrease in tactile fremitus? A client with:
- A. Emphysema
- B. Pneumonia
- C. Tuberculosis
- D. A lung tumor
Correct Answer: A
Rationale: Emphysema causes air trapping and hyperinflation, reducing tactile fremitus due to decreased transmission of vocal vibrations through the lungs.
The nurse is making assignments for the day. The staff consists of an RN, a novice RN, an LPN, and a nursing assistant. Which client should be assigned to the RN?
- A. A client with peptic ulcer disease
- B. A client with skeletal traction for a fractured femur
- C. A client with an abdominal cholecystectomy
- D. A client with an esophageal tamponade
Correct Answer: D
Rationale: The client with an esophageal tamponade requires complex monitoring and intervention, best suited for an experienced RN.
A client has been receiving Rheumatrex (methotrexate) for severe rheumatoid arthritis. The nurse should tell the client to avoid taking:
- A. Aspirin
- B. Multivitamins
- C. Omega 3 fish oils
- D. Acetaminophen
Correct Answer: A
Rationale: Aspirin can increase methotrexate toxicity by reducing its renal excretion, leading to potentially severe side effects.
A critically injured woman is rushed to the ER. She needs an immediate blood transfusion, and there is no time to crossmatch blood type. The nurse anticipates the physician will call for
- A. 1 unit of AB positive blood.
- B. 1 unit of O positive blood.
- C. 1 unit of AB negative blood.
- D. 1 unit of O negative blood.
Correct Answer: D
Rationale: O negative blood is the universal donor, safe for emergency transfusions without crossmatching, minimizing reaction risk.
A home health nurse visits a 7-year-old boy on neutropenic precautions. His mother cares for him during the day. Which of the following statements by the mother indicates a need for further teaching?
- A. I will call the doctor if my son has a temperature above 38°C.'
- B. My son should protect his skin by showering every other day instead of daily.'
- C. His aunt cannot visit until 3 weeks have passed since her flu shot.'
- D. I will need to throw out the flowers he got as a get-well gift.'
Correct Answer: C
Rationale: Live vaccines (e.g., nasal flu vaccine) require a 3-week wait, but the standard flu shot is inactivated, posing no risk. The other statements are correct for neutropenic precautions.