Nokea
The nurse is caring for a client several days following a cerebral vascular accident. Coumadin (warfarin) has been prescribed. Today's prothrombin level is 40 seconds (normal range 10-14 seconds). Which of the following findings requires priority follow-up?
- A. Gum bleeding
- B. Lung sounds
- C. Homan's sign
- D. Generalized weakness
Correct Answer: A
Rationale: The prothrombin time is elevated, indicating a high risk for bleeding. Neurological assessments remain important for post-CVA clients.
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The nurse is caring for a client who is attempting to leave the hospital against medical advice. The client is competent to make decisions. Which of the following actions would be essential for the nurse to take?
- A. Provide the client with a copy of the client’s medical record
- B. Tell the client that discharge forms must be signed before leaving
- C. Inform the client that the client cannot return for medical care after leaving
- D. Ensure the health care provider explains the risks of leaving the hospital to the client
Correct Answer: D
Rationale: Ensuring the provider explains risks ensures informed decision-making, protecting the client and minimizing liability. Medical records are not immediately provided, forms are procedural, and barring future care is incorrect.
The nurse is caring for an elderly client after hip replacement surgery. The client is distressed because he has not had a bowel movement in 3 days. Which action by the nurse would be most appropriate?
- A. Administer the prescribed as-needed milk of magnesia
- B. Ask dietary services to add more fruits and vegetables to the client’s tray
- C. Notify the registered nurse
- D. Perform a focused abdominal assessment
Correct Answer: D
Rationale: A focused abdominal assessment determines the cause of constipation (e.g., impaction, obstruction) before interventions like laxatives, dietary changes, or RN notification, ensuring safe and targeted care.
The nurse in a well-child clinic examines many children on a daily basis. Which of the following toddlers requires further follow up?
- A. A 13 month-old unable to walk
- B. A 20 month-old only using 2 and 3 word sentences
- C. A 24 month-old who cries during examination
- D. A 30 month-old only drinking from a sippy cup
Correct Answer: D
Rationale: A 30 month-old only drinking from a sippy cup. A 30 month-old should be able to drink from a cup without a cover.
A client who is blind is admitted to the hospital for surgery tomorrow. The client is able to get out of bed and eat until midnight. Which nursing action is most appropriate?
- A. Describe the surroundings and the objects in the room to the client.
- B. Put up the side rails and have the client ask for help when getting out of bed for any reason.
- C. Describe the voices of the personnel to the client.
- D. Remove objects such as water pitchers and glasses from the immediate vicinity.
Correct Answer: A
Rationale: Describing surroundings aids orientation and safety for a blind client, promoting independence. Side rails, voice descriptions, or removing objects are less helpful.
The nurse observes a client self-administering nasal fluticasone. Which observation would require the practical nurse to intervene and reinforce the instructions provided by the registered nurse?
- A. A sitting position is assumed as the head is bowed slightly forward
- B. The client points the spray tip toward the nasal septum during instillation
- C. The nasal spray tip is inserted into the nostril as the other nostril is occluded
- D. While administering the medication, the client inhales deeply through the nose
Correct Answer: B
Rationale: Pointing fluticasone toward the nasal septum risks irritation or bleeding; it should be aimed laterally. Sitting with head forward, occluding the other nostril, and inhaling deeply are correct administration techniques.