Nokea
The nurse is caring for a client admitted 3 days ago with bacterial pneumonia who has become short of breath, restless, and difficult to rouse. Which additional finding indicates to the nurse that the client may be developing sepsis?
- A. Capillary refill time of 5 seconds
- B. Diminished breath sounds in the lung bases
- C. Hyperactive bowel sounds
- D. Urine output of 35 mL/hr
Correct Answer: A
Rationale: Prolonged capillary refill time suggests poor perfusion, a sign of sepsis, requiring immediate intervention.
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The nurse is caring for a client who had a surgical excision and biopsy of a tumor. The biopsy results show that the tumor is malignant, but the client has not yet been informed by the health care provider. The client asks the nurse, 'Am I going to die?' Which of the following responses would be appropriate for the nurse to make?
- A. You seem upset. Tell me more about how you are feeling about this situation.
- B. I understand that you feel anxious. Maybe watching television will help you relax.
- C. Waiting for test results can be very stressful. I am sure that it will all work out.
- D. The biopsy results show that you have cancer. However, many cancers are treatable.
Correct Answer: A
Rationale: Exploring the client's feelings is supportive and appropriate, as the nurse should not disclose results before the provider.
The licensed vocational nurse cannot assume the primary care for a client:
- A. In the fourth stage of labor
- B. Two days post appendectomy
- C. With a venous access device
- D. With bipolar disorder
Correct Answer: A
Rationale: The fourth stage of labor requires advanced nursing skills due to potential complications, unsuitable for an LVN's primary role. Post-appendectomy , venous access , and bipolar disorder are within LVN scope.
A nurse is preparing for a medical relief trip to West Africa and is concerned about a disruption in circadian rhythm from traveling across several time zones. Which supplement might help synchronize the body to environmental time?
- A. Evening primrose
- B. Ginseng
- C. Melatonin
- D. St. John wort
Correct Answer: C
Rationale: Melatonin helps regulate sleep-wake cycles and can mitigate jet lag.
The nurse is assisting with the care of a client who is scheduled to receive an oxytocin infusion to induce labor. The nurse should recognize that oxytocin infusion can lead to
- A. decreased risk for postpartum hemorrhage
- B. fetal distress and cesarean birth
- C. increased risk for placenta previa
- D. preeclampsia and hypernatremia
Correct Answer: B
Rationale: Oxytocin can cause uterine hyperstimulation, leading to fetal distress and potential cesarean delivery.
A nurse has been assigned to provide care to a client with suicidal ideation who is receiving treatment in an outpatient setting. The nurse develops a care plan and reviews it with the nurse preceptor before meeting with the client. Which proposed nursing action in the care plan requires intervention by the nurse preceptor?
- A. Assist the client in identifying the warning signs of a crisis
- B. Have the client write a list of people to contact for help and distraction
- C. Help the client develop ways of coping with suicidal thoughts
- D. Persuade the client to sign a contract promising not to attempt suicide
Correct Answer: D
Rationale: No-suicide contracts are not evidence-based and may create pressure rather than support coping strategies.