Nokea
The nurse is caring for 4 clients. Which client should the nurse see first?
- A. 2 days post abdominal aortic aneurysm repair with weak pedal pulses and mottled skin on the legs
- B. 2 days post coronary bypass graft surgery with a white blood cell count of 16,000/mm³ (16.0 × 10â¹/L)
- C. Chronic heart failure with peripheral edema and shortness of breath on exertion
- D. Pneumothorax with a chest tube to negative suction and subcutaneous emphysema
Correct Answer: A
Rationale: Weak pulses and mottled skin suggest vascular compromise, a life-threatening complication requiring immediate attention. The other conditions are less urgent.
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An RN from the women's health clinic is temporarily reassigned to a medical-surgical unit. Which of these client assignments would be most appropriate for this nurse?
- A. A newly diagnosed client with type 2 diabetes mellitus who is learning foot care
- B. A client from a motor vehicle accident with an external fixation device on the leg.
- C. A client admitted for a barium swallow after a transient ischemic attack
- D. A newly admitted client with a diagnosis of pancreatic cancer
Correct Answer: B
Rationale: This client is the most stable, requires basic safety measures and has a predictable outcome.
The nurse has reinforced teaching with the parents of a 6-year-old client with chronic allergic rhinitis that is triggered by dust and pollen. Which of the following statements by the parents would indicate a correct understanding of the teaching? Select all that apply.
- A. We are planning to purchase an air purifier with a high-efficiency particulate air filter
- B. We will keep the windows open during warm weather to air out our house.
- C. We should place hypoallergenic covers on our child's mattress and pillow.
- D. We will clean our wood floors with a damp mop at least once a week
- E. We are planning to remove the carpet from our child's bedroom.
Correct Answer: A,C,D,E
Rationale: Correct choices reduce allergen exposure: HEPA filters remove dust/pollen, hypoallergenic covers prevent dust mite exposure, damp mopping reduces dust, and removing carpets eliminates allergen reservoirs. Keeping windows open increases pollen exposure, worsening symptoms.
The nurse is screening clients for those at risk of developing syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should recognize that the client at highest risk for developing SIADH is a client with
- A. carpal tunnel syndrome
- B. small cell lung cancer
- C. osteomyelitis
- D. sciatica
Correct Answer: B
Rationale: Small cell lung cancer is strongly associated with SIADH due to ectopic ADH production. Other conditions listed are not significant risk factors.
The nurse caring for newborns observes for jaundice. Which type of jaundice is likely to be most serious?
- A. Jaundice that occurs during the first day of life
- B. Jaundice occurring after 48 hours of life
- C. Jaundice occurring 7 to 10 days after birth
- D. Any jaundice is potentially life threatening.
Correct Answer: A
Rationale: Jaundice within the first 24 hours suggests pathological causes like hemolytic disease, requiring urgent evaluation. Later jaundice is often physiologic and less severe.
The nurse is teaching an elderly client how to use MDIs (multi-dose inhalers). The nurse is concerned that the client is unable to coordinate the release of the medication with the inhalation phase. What is the nurse's best recommendation to improve delivery of the medication?
- A. Nebulized treatments for home care
- B. Adding a spacer device to the MDI canister
- C. Asking a family member to assist the client with the MDI
- D. Request a visiting nurse to follow the client at home
Correct Answer: B
Rationale: If the client is not using the MDI properly, the medication can get trapped in the upper airway, resulting in dry mouth and throat irritation. Using a spacer will allow more drug to be deposited in the lungs and less in the mouth.