Nokea
The nurse is caring for a client diagnosed with generalized anxiety disorder. What behavior demonstrates that the client is building resilience toward improving anxiety symptoms?
- A. Avoids anxiety-producing situations
- B. Identifies anxiety-reducing triggers
- C. Practices stress-reduction techniques daily
- D. Relies on medication to manage symptoms
Correct Answer: C
Rationale: Practicing stress-reduction techniques daily, such as mindfulness or deep breathing, actively builds resilience by equipping the client with tools to manage anxiety symptoms effectively. Avoiding situations may reinforce anxiety, identifying triggers is helpful but less proactive, and relying solely on medication does not foster long-term resilience.
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A nurse from the surgical department is reassigned to the pediatric unit. The charge nurse should recognize that the child at highest risk for cardiac arrest and is the least likely to be assigned to this nurse is which child?
- A. Congenital cardiac defects
- B. An acute febrile illness
- C. Prolonged hypoxemia
- D. Severe multiple trauma
Correct Answer: C
Rationale: Prolonged hypoxemia. Most often, the cause of cardiac arrest in the pediatric population is prolonged hypoxemia, requiring specialized monitoring.
Quality is defined as a combination of all of the following except:
- A. conforming to standards.
- B. performing at the minimally acceptable level.
- C. meeting or exceeding customer requirements.
- D. exceeding customer expectations.
Correct Answer: B
Rationale: Quality care involves meeting or exceeding standards and expectations, not merely performing at a minimal level, which is insufficient for quality. Coordinated Care
The nurse is caring for a 70-year-old client with diabetic retinopathy. Which of the following statements by the client would be a priority to follow up?
- A. Half of my vision looks like it is being covered by a curtain
- B. I wear reading glasses when reading the newspaper
- C. My vision is cloudy with a glare around bright lights
- D. Colors appear less bright than when I was younger
Correct Answer: A
Rationale: A 'curtain' over half the vision suggests retinal detachment, a medical emergency requiring immediate intervention to prevent permanent vision loss. Reading glasses are normal, cloudy vision or glare may indicate cataracts, and less bright colors are age-related, but none are as urgent.
The nurse is caring for a client with an exacerbation of chronic obstructive pulmonary disease and pneumonia. The nurse notes that the client has become disoriented and restless and becomes concerned that the client may have impaired oxygenation due to poor secretion clearance. Which is the nurse’s priority action?
- A. Administer lorazepam 1 mg IM
- B. Administer oxygen using venturi mask
- C. Maintain IV normal saline infusion at prescribed rate of 125 mL/hr
- D. Place the head of the bed in semi-Fowler position
Correct Answer: B
Rationale: Disorientation and restlessness suggest hypoxia. Administering oxygen via a venturi mask delivers precise oxygen concentrations to improve oxygenation, addressing the priority concern. Lorazepam may worsen respiratory depression, IV fluids do not address hypoxia, and semi-Fowler aids breathing but is secondary.
The physician orders the antibiotics ampicillin (Omnipen) and gentamicin (Garamycin) for a newly admitted client with an infection. The nurse should:
- A. administer both medications simultaneously.
- B. give the medications sequentially, and flush well between them.
- C. ask the physician or pharmacy which medication to give first and how long to wait before giving the other drug.
- D. start one medication now and begin the other medication in 2-4 hours.
Correct Answer: B
Rationale: Ampicillin and gentamicin are pH-incompatible, so they must be given sequentially with thorough flushing to prevent precipitation in the IV line. Simultaneous or delayed administration is inappropriate. Pharmacological Therapies