Nokea
The nurse is caring for a client with uncontrolled hypertension. Which findings require immediate nursing action?
- A. lower extremity pitting edema
- B. rales
- C. jugular vein distension
- D. weakness in left arm
Correct Answer: D
Rationale: weakness in left arm. In a client with hypertension, weakness in the extremities is a sign of cerebral involvement with the potential for cerebral infarction or stroke. Cerebral infarctions account for about 80% of the strokes in clients with hypertension. The remaining three choices indicate mild fluid overload and are not medical emergencies.
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After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is
- A. abdominal x-ray
- B. auscultation
- C. flushing tube with saline
- D. aspiration for gastric contents
Correct Answer: A
Rationale: abdominal x-ray. Placement should be verified by radiograph to determine that the tube is in the stomach or intestine rather than in the airways.
The client is placed on contact precautions. When should the nurse caring for the client plan to put on disposable examination gloves?
- A. As soon as the nurse enters the client's room
- B. Only if anticipating contact with the client's wound
- C. Only if anticipating contact with blood or body fluids
- D. Only if providing care within 3 feet of the client
Correct Answer: A
Rationale: A: Contact precautions require gloves upon entering the room to prevent transmission of infectious organisms, regardless of anticipated contact.
The nurse is preparing to care for the client with Ebola, a febrile, hemorrhagic disease. After selecting a disposable surgical hood that extends to the shoulders, what additional PPE should the nurse obtain? Select all that apply.
- A. Docimeter
- B. Disposable N95 respirator
- C. Disposable full face shield
- D. Cloth gown that cannot be reused
- E. Two pair nitrile examination gloves
- F. Boot covers extending to mid-calf
Correct Answer: B,C,E,F
Rationale: B: N95 respirator protects against possible airborne transmission. C: Face shield prevents mucosal exposure. E: Double gloves enhance protection. F: Boot covers prevent lower leg exposure. A: Docimeters are for radiation. D: Cloth gowns are inadequate; impermeable gowns are needed.
Which of these statements from clients who call the community health clinic would suggest the need for a same-day appointment to be seen by the health care provider?
- A. I started my period and now my urine has turned bright red'
- B. I am a diabetic and today I have been going to the bathroom every hour'
- C. I was started on medicine yesterday for a urine infection. Now my lower belly hurts when I go to the bathroom'
- D. I went to the bathroom and my urine looked very red and it didn't hurt when I went'
Correct Answer: D
Rationale: With this description of symptoms this client needs to be seen that day since painless gross hematuria is closely associated with bladder cancer. The other complaints can be handled over the phone.
Which of these food choices, if selected by a client with diarrhea, would indicate the need for further teaching about dietary management?
- A. orange juice
- B. tuna
- C. eggs
- D. macaroni
Correct Answer: A
Rationale: Orange juice is contraindicated for a client with diarrhea because it increases the motility of the gastrointestinal tract.