Nokea
The nurse is caring for a group of clients. Which finding requires immediate action by the nurse?
- A. Client scheduled for discharge who has had a peripheral IV in place for 84 hours
- B. Client with a do-not-resuscitate prescription who has swelling at the IV site
- C. Client with a saline lock who had a scheduled IV saline flush due 15 minutes ago
- D. Client with an IV infusing at 20 mL/hr who has 100 mL fluid remaining in the bag
Correct Answer: A
Rationale: A peripheral IV in place for 84 hours increases the risk of infection and phlebitis. Guidelines recommend changing IV sites every 72-96 hours, so this requires immediate action to remove or replace the IV.
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The practical nurse is collecting data on a client receiving methotrexate to treat rheumatoid arthritis. Which finding associated with this drug is most important for the nurse to report to the registered nurse?
- A. Hair loss
- B. Nausea
- C. Petechiae
- D. Stomatitis
Correct Answer: C
Rationale: Petechiae indicate thrombocytopenia, a serious adverse effect of methotrexate, risking bleeding and requiring immediate reporting for dose adjustment or discontinuation.
The nurse is assigned to care for 4 clients. Which of the following should be assessed immediately after hearing the report?
- A. The client with asthma who is now ready for discharge
- B. The client with a peptic ulcer who has been vomiting all night
- C. The client with chronic renal failure returning from dialysis
- D. The client with pancreatitis who was admitted yesterday
Correct Answer: B
Rationale: The client with a peptic ulcer who has been vomiting all night. Persistent vomiting can lead to dehydration, electrolyte imbalances, and potential complications such as perforation or bleeding in a client with a peptic ulcer, requiring immediate assessment.
The nurse is contributing to the plan of care for an 8-year-old client with autism spectrum disorder. Which of the following interventions should the nurse suggest including in the client's plan of care? Select all that apply.
- A. Establish a consistent schedule for providing care.
- B. Encourage the parents to be present when providing care.
- C. Assign the same staff members to care for the client when possible.
- D. Place the client in a private room with familiar belongings.
- E. Use therapeutic touch to comfort the client.
Correct Answer: A,B,C,D
Rationale: Consistency in schedule (A), parental presence (B), familiar staff (C), and a private room with familiar items (D) reduce anxiety in children with autism. Therapeutic touch (E) may be distressing due to sensory sensitivities.
The practical nurse collaborates with the registered nurse to perform an admission assessment on a client with Alzheimer disease. Which of the following techniques are appropriate when speaking with this client? Select all that apply.
- A. Ask open-ended questions
- B. Move close to the client and speak in a loud voice
- C. Remove background noise by turning off the television
- D. Touch the client on shoulder prior to speaking
- E. Use clear and simple sentences
Correct Answer: C,D,E
Rationale: Reducing background noise (C) minimizes distractions. Touching the shoulder (D) gains attention non-verbally. Using clear, simple sentences (E) accommodates cognitive impairments in Alzheimer disease.
A client hospitalized with mania is racing wildly about the unit trying to organize the other clients into a game of Ping-Pong. The nurse should:
- A. Send the client to the recreation room for art therapy.
- B. Take the client outside for a walk.
- C. Allow the client to continue because his activities are goal directed.
- D. Suggest that the client do exercises to a video instead.
Correct Answer: B
Rationale: Taking the client for a walk redirects energy safely and reduces stimulation. Art therapy may not engage, continuing the activity risks escalation, and video exercises lack supervision.