Nokea
The nurse is caring for a client who has developed retinal detachment. Which of the following actions should the nurse take first?
- A. Instruct the client to restrict activity
- B. Establish a vascular access device
- C. Review the client's current medications
- D. Educate the client about topical eye ointments
Correct Answer: A
Rationale: Restricting activity is the first priority to prevent further retinal damage.
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The nurse is reviewing a client's list of medications who has cystic fibrosis. The nurse anticipates a prescription for which medication?
- A. Multivitamin
- B. Aspirin
- C. Warfarin
- D. Simvastatin
- E. Salmeterol
Correct Answer: A, E
Rationale: Multivitamins address malabsorption, and salmeterol helps manage airway obstruction in cystic fibrosis.
The nurse is caring for a client with hypernatremia. Which prescribed intravenous fluid (IVF) would be appropriate?
- A. Dextrose 5% in water (D5W)
- B. 3% saline
- C. Lactated Ringer's 5% Dextrose in Water (D5LR)
- D. 0.9% saline
Correct Answer: A
Rationale: D5W is hypotonic and helps correct hypernatremia by diluting serum sodium levels.
The nurse is caring for a client who is recovering from surgery. Which assessment data would suggest that the client's pain is not well controlled?
- A. Tachypnea
- B. Bradycardia
- C. Nausea
- D. Mydriasis
- E. Increased blood glucose
Correct Answer: A, C, E
Rationale: Tachypnea, nausea, and increased blood glucose are signs of uncontrolled pain.
The following scenario applies to the next 5 items
The nurse in the emergency department (ED) is caring for a 10-year-old client.
Item 1 of 5
Nurses' Notes
1322: 10-year-old client and his parents report an 8-day history of a brownish-raised lesion over the back of his left leg. The parents report that the size of the rash has increased. The parents report returning from a one-week camping trip three weeks ago. The parents deny efficacy with over-the-counter antihistamine creams. The client's parents deny that the child has had a fever but has felt 'warm' occasionally and endorsed an intermittent headache. They report an area of firmness in the child's groin. On assessment, there was an erythematous, raised, nonpainful, oval patch on the back of his left leg. This was an enlargement of an inguinal lymph node. The child is alert and fully oriented and denies any pain. Peripheral pulses palpable 2+. No cyanosis or edema in the extremities. Lung sounds clear bilaterally. The parents report that the child did not receive the seasonal influenza vaccine. He currently takes a multivitamin for iron deficiency anemia and was hospitalized one year ago for an appendectomy. The parents state that the child’s sibling had influenza one month ago. Vital signs: T 98.8°F (37.1°C); HR 78 beats/min; RR 16 breaths/min; BP 110/76 mm Hg. SpO2 97% on room air.
Which of the following would require immediate follow-up?
- A. temperature and pulse oximetry reading
- B. pulse, respirations, and blood pressure
- C. medical and surgical history
- D. integumentary assessment findings
- E. lymph node assessment
- F. recent camping trip
- G. immunization status
Correct Answer: D, E, F
Rationale: The bullseye rash, inguinal lymphadenopathy, and recent camping trip suggest Lyme disease, requiring immediate follow-up.
The nurse in the emergency department (ED) is caring for a 64-year-old male client.
Item 3 of 6
Nurses' Notes
1742: Client arrives at the emergency department via emergency medical services (EMS). He was skiing and crashed into a post and fell to the ground. Ski patrol assessed the client, and the client was confused and had no memory of the crash. Ski patrol reports that he was wearing a helmet and had a loss of consciousness for an unknown amount of time. On assessment, the client was alert and oriented to place and time but did not recall the events leading up to hospitalization, specifically the ski crash. Client states, “My head really hurts and I'm dizzy.” Reporting aching pain rated 8/10 on the Numerical Pain Scale. Reddish contusion on the client's forehead. Pupils were 2+, equal, and sluggishly reactive to light. Glasgow Coma Scale 14. Nose is midline and symmetrical. His speech was clear and articulate. Full range of motion in all extremities observed. Clear lung fields bilaterally. Radial pulse 2+ and irregular. Normoactive bowel sounds in all quadrants. No abdominal distention or pain. Vital signs: T 97.8° F (36.6° C), P 85, RR 15, BP 124/82, pulse oximetry reading 98% on room air. The client has a medical history of essential hypertension, generalized anxiety disorder, atrial fibrillation, and chronic back pain.
Home medications
• multivitamin (MVI) 1 tablet PO daily
• fluoxetine 20 mg PO daily
• biotin 100 mcg PO daily
• pantoprazole 40 mg PO daily
• warfarin 2.5 mg PO daily
• diltiazem controlled-release 120 mg PO daily
Complete the following sentence by choosing from the list of options. The nurse should prioritize obtaining an order for a ___ and ___ to better determine the extent of the client's injuries.
- A. radiograph (x-ray) of the head and neck
- B. electrocardiogram
- C. electroencephalogram
- D. computed tomography scan of the head
- E. hematocrit
- F. platelet count
- G. international normalized ratio
Correct Answer: D, G
Rationale: A CT scan of the head is critical to assess for brain injury, and INR is necessary due to warfarin use and bleeding risk.