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The nurse is assisting with procedural moderate sedation (conscious sedation) at a client's bedside. The unlicensed assistive personnel (UAP) comes to the door and indicates that the client in the next room needs the nurse right now. How should the nurse respond?
- A. Ask the UAP to go back and ask the client what the current needs are
- B. Ask the UAP to stay and take over while the nurse goes to check on the client in the next room
- C. Tell the UAP to inform the client in the next room that the nurse will be there shortly
- D. Tell the UAP to tell the charge nurse about the needs of the client in the next room
Correct Answer: D
Rationale: During moderate sedation, the nurse must remain with the client to monitor vital signs and response. Directing the UAP to inform the charge nurse ensures the other client's needs are addressed without compromising the sedated client's safety. UAP cannot monitor sedation or take over.
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A client is admitted with severe injuries from an auto accident. The client's vital signs are BP 120/50, pulse rate 110, and respiratory rate of 28. The initial nursing intervention would be to
- A. begin intravenous therapy
- B. initiate continuous blood pressure monitoring
- C. administer oxygen therapy
- D. institute cardiac monitoring
Correct Answer: C
Rationale: Early findings of shock reveal hypoxia with rapid heart rate and rapid respirations, and oxygen is the most critical initial intervention. The other interventions are secondary to oxygen therapy.
The nurse is caring for a 4-year-old client with cystic fibrosis who uses a high-frequency chest wall oscillation (HFCWO) vest for chest physiotherapy. After reinforcing education with the client's parents, which statement by a parent requires further teaching?
- A. I will allow my child to have a snack while using the HFCWO vest to encourage cooperation.
- B. I will give my child the nebulized bronchodilator treatment during therapy with the HFCWO vest.
- C. I will perform manual chest percussion on my child if the HFCWO vest is broken or unavailable.
- D. My child will use the HFCWO vest once in the morning, once in the evening, and as needed.
Correct Answer: A
Rationale: Eating during HFCWO vest use can increase the risk of aspiration or reduce therapy effectiveness, indicating a need for further teaching. Bronchodilators during therapy, manual percussion as a backup, and the described frequency are appropriate.
An adult is admitted to the hospital with several days of vomiting and diarrhea. Admitting data show RBC level of 4.2 million/mm³ and hematocrit of 54%. What is the best interpretation of these data?
- A. The client may have internal bleeding.
- B. The client is probably dehydrated.
- C. These are normal findings.
- D. The client is anemic.
Correct Answer: B
Rationale: Elevated hematocrit (normal: 36-46% for females, 41-53% for males) with normal RBC suggests hemoconcentration from dehydration due to fluid loss from vomiting and diarrhea.
A client has just been prescribed allopurinol for chronic gout. Which instruction is most important for the nurse to reinforce to the client?
- A. Report for periodic laboratory tests for kidney, liver, and blood functions
- B. Store the medication in a cool, dry place away from direct heat and light
- C. Take the medication after a meal to prevent gastric distress
- D. Take the medication with a full glass of water and increase fluids during the day
Correct Answer: A
Rationale: Allopurinol can affect kidney, liver, and bone marrow function, so periodic lab tests are critical to monitor for toxicity. Storage instructions, taking with food, and fluid intake are important but less critical than ensuring organ function safety.
The practical nurse is assisting the registered nurse in performing well-child examinations in a pediatric clinic. Which finding requires further evaluation?
- A. Chest rounded with the anteroposterior diameter equal to the lateral diameter in an infant
- B. Lateral curvature to the spine noted on examination of a 10-year-old girl
- C. Presence of an S3 heart sound in a 2-year-old
Correct Answer: B
Rationale: Lateral curvature of the spine in a 10-year-old suggests scoliosis, which requires further evaluation to prevent progression. A rounded chest in infants is normal due to developing lungs, and an S3 heart sound can be normal in young children.