Nokea
The nurse is caring for a client who reported having thoughts of self-injury yesterday. Which of the following statements by the client should the nurse recognize as risk factors for suicide? Select all that apply.
- A. I am currently unemployed and looking for a job
- B. I have been married for five years with three children
- C. I have multiple firearms at home stored in a safe
- D. I have been about a year since I last overdosed
- E. I attend weekly religious activities with my family
- F. Sometimes I experience feelings of hopelessness
Correct Answer: A,C,D,F
Rationale: Unemployment, access to firearms, prior overdose, and hopelessness are established suicide risk factors. Marriage with children and religious activities are protective factors.
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An 80-year-old woman has been hospitalized for three days with pneumonia. She is now able to sit in a chair for the first time. How should the nurse plan care for today?
- A. Give her a bed bath and make her bed. Get her up in the chair later.
- B. Get her up in the chair and have her give herself a bath while the nurse makes the bed.
- C. Give her a bed bath and come back later to get her up in the chair. Make the bed while she is up in the chair.
- D. Give her a bed bath and immediately get her up in the chair so the bed can be made.
Correct Answer: C
Rationale: A bed bath conserves energy, and later chair transfer allows bed-making, optimizing rest and mobility for a recovering pneumonia patient.
What nursing action is essential when oxygen is ordered for a client who is living at home?
- A. Assist the client and family in checking all electrical appliances in the vicinity for frayed cords.
- B. Encourage the client and family to purchase fire extinguishers.
- C. Remove electrical devices from the room where oxygen is in use.
- D. Encourage the client and family to carpet the client's room.
Correct Answer: A
Rationale: Checking for frayed cords reduces fire risk, as oxygen supports combustion. Extinguishers are secondary, removing devices is impractical, and carpeting increases static sparks.
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.
Which tasks can the licensed practical nurse appropriately delegate to unlicensed assistive personnel? Select all that apply.
- A. Assist the nurse in ambulating a client 1 day post abdominal surgery
- B. Measure and empty drainage output into a bulb drain
- C. Monitor for redness and swelling at a client’s IV insertion site
- D. Provide extra blankets at the client’s request
- E. Take family members to the waiting room after a client goes into surgery
Correct Answer: A,B,D,E
Rationale: Assisting with ambulation, measuring drainage, providing blankets, and escorting family are within UAP scope with proper training. Monitoring IV sites requires nursing judgment and is not delegable.
The client is admitted to the labor and delivery unit with preeclampsia. An IV of magnesium sulfate is begun per pump. Which finding would indicate hypermagnesemia?
- A. Urinary output of $60 \mathrm{ml}$ per hour
- B. Respirations of 30 per minute
- C. Absence of the knee-jerk reflex
- D. Blood pressure of $150 / 80$
Correct Answer: C
Rationale: Hypermagnesemia, a risk of magnesium sulfate therapy, causes symptoms like loss of deep tendon reflexes (e.g., knee-jerk reflex), respiratory depression, and hypotension. Urinary output of 60 ml/hour is normal, respirations of 30 suggest tachypnea, and BP of 150/80 is not specific to hypermagnesemia.