Nokea
The nurse is caring for a client with a deep vein thrombosis. Which finding would require the nurse's immediate attention?
- A. Temperature of 102 degrees Fahrenheit
- B. Pulse rate of 98 beats per minute
- C. Respiratory rate of 32
- D. Blood pressure of 90/50
Correct Answer: C
Rationale: Respiratory rate of 32. Clients with deep vein thrombosis are at risk for the development of pulmonary embolism (PE). The most common symptoms of PE are tachypnea, dyspnea, and chest pain.
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A 3-year-old child who is up to date with all immunizations is seen at clinic. The child has a fever of 102°F and a pruritic rash with fluid-filled vesicles that began on the trunk. The physician says the child has varicella. The child's mother says to the nurse, 'I thought my child couldn't get this because she had all her shots.' What is the best response for the nurse to make?
- A. You child probably did not respond to the vaccine as most children do.
- B. The nurse must not have administered it correctly.
- C. It is still possible to contract the illness, but your child will most likely have a less severe case.
- D. The vaccine is only effective after the child has received two doses.
Correct Answer: C
Rationale: The varicella vaccine reduces severity but does not guarantee immunity; breakthrough cases are milder, as indicated by the child's symptoms.
The nurse is providing home care. Which assessment finding would suggest to the nurse that the elderly client should be evaluated for abuse?
- A. The client says, 'My daughter takes some of my Social Security money. She says it's to pay for my food and medicine.'
- B. The client has several bruises on her arms and legs.
- C. The client says her family is mean because they hire someone to stay with her when they go out.
- D. The client has several bruises and circular marks that look like cigarette burns on her back.
Correct Answer: D
Rationale: Bruises and circular marks resembling cigarette burns strongly suggest physical abuse, requiring immediate evaluation. Unexplained bruises are concerning but less specific, and the other options may reflect misunderstanding or caregiving arrangements.
The provisions of the law for the Americans with Disabilities Act require nurse managers to
- A. Maintain an environment free from associated hazards
- B. Provide reasonable accommodations for disabled individuals
- C. Make all necessary accommodations for disabled individuals
- D. Consider both mental and physical disabilities
Correct Answer: B
Rationale: The law is designed to permit persons with disabilities access to job opportunities. Employers must evaluate an applicant's ability to perform the job and not discriminate on the basis of a disability. Employers also must make 'reasonable accommodations.'
A client returns from surgery after an open reduction of a femur fracture. There is a small bloodstain on the cast. Four hours later, the nurse observes that the stain has doubled in size. What is the best action for the nurse to take?
- A. Call the health care provider
- B. Access the use of a window in the cast
- C. Simply record the findings in the nurse's notes only
- D. Outline the spot with a pencil and note the time and date on the cast
Correct Answer: D
Rationale: Outline the spot with a pencil and note the time and date on the cast. This is a good way to assess the amount of bleeding over a period of time. The bleeding does not appear to be excessive and some bleeding is expected with this type of surgery. The bleeding should also be documented in the nurse's notes.
The nurse is caring for clients in the outpatient clinic. A young adult female is seeking help for weight loss. Her weight is 257 pounds, and she is 5'7'' tall.
Which of the following indicates the MOST appropriate diet choices for breakfast?
- A. Applesauce, cream of wheat, toast.
- B. Scrambled eggs and toast, one slice of bacon.
- C. One glass of grapefruit juice.
- D. Bagel with two ounces of cream cheese and a banana.
Correct Answer: A
Rationale: Strategy: Determine the topic of the question. (1) correct-breakfast with some substance won't leave her feeling hungry most of the morning (2) high fat content (3) doesn't provide a balance of nutrients and may leave the client feeling very hungry before lunch (4) high fat content