Nokea
The nurse is caring for a client with immune thrombocytopenic purpura. Which client statements indicate a need for further teaching? Select all that apply.
- A. I use a soft-bristle toothbrush and mild mouth rinse.
- B. I enjoy walking and wear nonskid footwear for safety.
- C. I use a safety razor and gentle shaving cream.
- D. I sometimes get constipated, so I have been taking docusate.
- E. I when I have a headache, I take over-the-counter ibuprofen.
Correct Answer: C,E
Rationale: ITP increases bleeding risk. Using a safety razor (C) risks cuts, and ibuprofen (E) inhibits platelets, both requiring further teaching. Soft toothbrush (A), safe walking (B), and docusate (D) are appropriate.
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The nurse is caring for assigned clients. The nurse should first check the
- A. 3-year-old client who has fever and right hip pain and is refusing to move the right leg
- B. 7-year-old client who has sinus congestion and a productive cough
- C. 10-year-old client who has an active nosebleed and is applying pressure to the nose
- D. 12-year-old client who has fever, urinary frequency, and dysuria
Correct Answer: A
Rationale: A 3-year-old with fever, hip pain, and refusal to move the leg (A) may indicate a serious condition like septic arthritis or osteomyelitis, requiring immediate assessment to prevent joint damage or systemic infection. Sinus congestion (B) and urinary symptoms (D) are less urgent, and the nosebleed (C) is being managed with pressure, making them lower priorities.
A client is receiving IV potassium. The IV pump displays an occlusion alarm. The tubing is free of occlusions, and the IV flushes easily without symptoms of infiltration. Which action should the nurse take next?
- A. Discard potassium and document administration of a partial dose
- B. Exchange the IV pump with a different one
- C. Insert a new IV catheter in a different location
- D. Remove the pump and administer medication by gravity drip
Correct Answer: B
Rationale: An occlusion alarm with patent tubing suggests a pump malfunction. Exchanging the pump (B) ensures safe delivery. Discarding (A) is unnecessary, a new catheter (C) is not indicated, and gravity drip (D) risks rapid infusion.
Which activity is appropriate to assign to a certified nursing assistant?
- A. Evaluate vital signs.
- B. Monitor tube feedings.
- C. Assist with activities of daily living (ADLs).
- D. Discuss discharge instructions.
Correct Answer: C
Rationale: Assisting with ADLs is within a CNA's scope, unlike evaluating vitals, monitoring feedings, or discussing instructions, which require nursing judgment.
All of the following individuals live at home with their families. Which of the following persons is least at risk for abuse?
- A. An 82-year-old woman who is incontinent and bosses people around
- B. An 80-year-old man who is ambulatory with help following a brain attack
- C. A 78-year-old woman who asks for help with all of her activities of daily living
- D. A 75-year-old man who wanders at night and frequently yells out
Correct Answer: B
Rationale: The ambulatory man with minimal dependency is least likely to be abused, as he retains some independence. Incontinence, high dependency, or disruptive behavior increase vulnerability.
The nurse is completing a client's intake and output record for the shift. How many mL should the nurse record as the client's net fluid balance for the shift?
Correct Answer: 890
Rationale: Without specific intake/output data, a general approach is assumed: net fluid balance is calculated as total intake (IV, oral, etc.) minus total output (urine, emesis, etc.). For example, if intake is 2000 mL and output is 1800 mL, the balance is 200 mL. The nurse must sum all recorded values accurately.