Nokea
The nurse is assigned to care for 4 clients. Which of the following should be assessed immediately after hearing the report?
- A. The client with asthma who is now ready for discharge
- B. The client with a peptic ulcer who has been vomiting all night
- C. The client with chronic renal failure returning from dialysis
- D. The client with pancreatitis who was admitted yesterday
Correct Answer: B
Rationale: The client with a peptic ulcer who has been vomiting all night. Persistent vomiting can lead to dehydration, electrolyte imbalances, and potential complications such as perforation or bleeding in a client with a peptic ulcer, requiring immediate assessment.
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A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the nurse enters the room to request something for pain. The nurse should
- A. Administer a placebo
- B. Encourage increased fluid intake
- C. Administer the prescribed analgesia
- D. Recommend relaxation exercises for pain control
Correct Answer: C
Rationale: Administer the prescribed analgesia. Pain relief is a priority in sickle cell crisis, and prescribed analgesics are appropriate.
The nurse cares for a child with bed bug bites. Which parent statement indicates that further teaching is required?
- A. I need to have the entire house treated by pest control to ensure the bed bugs are gone.
- B. I should concentrate on alleviating scratching as it can cause further complications.
- C. My other family members and pets are at risk of bed bug bites.
- D. This must have happened because I did not wash the bed sheets this week.
Correct Answer: D
Rationale: Bed bug infestations are not caused by unwashed sheets but by exposure to infested environments. This misconception indicates a need for further teaching about bed bug transmission and prevention.
The nurse is auscultating a client's breath sounds and identifies rhonchi. The nurse should recognize that rhonchi is consistent with
- A. croup
- B. pleurisy
- C. bronchitis
- D. pneumothorax
Correct Answer: C
Rationale: Rhonchi are low-pitched, rattling sounds caused by mucus or fluid in larger airways, commonly associated with bronchitis.
A 20-year-old woman is admitted to the hospital following an accident. Her uncle, a physician from out of state, visits her and asks to see her chart. How should the nurse respond?
- A. Comply with the request and give the chart to the physician
- B. Explain that written permission from his niece is needed first
- C. Suggest that he discuss the case with the attending physician
- D. Give him the chart but do not let him remove it from the nurse's station
Correct Answer: B
Rationale: HIPAA regulations require patient consent for chart access, even by a physician relative, unless they are directly involved in care. Permission from the patient is needed first.
The nurse is reinforcing teaching to an overweight 54-year-old client about ways to decrease symptoms of obstructive sleep apnea. Which interventions would be most effective? Select all that apply.
- A. Eating a high-protein snack at bedtime
- B. Limiting alcohol intake
- C. Losing weight
- D. Taking a mild sedative at bedtime
- E. Taking a nap during the day
- F. Taking modafinil at bedtime
Correct Answer: B,C
Rationale: Limiting alcohol (B) reduces airway relaxation, and losing weight (C) decreases airway obstruction, both directly alleviating sleep apnea symptoms.