Nokea
The nurse is caring for a schizophrenic client who has become increasingly withdrawn to the point of mutism. The MOST important nursing approach at this time would be to
- A. ignore the client until he is ready to respond.
- B. sit with the client for brief periods of time.
- C. read to the client in a quiet area of the unit.
- D. encourage the client to play dominos with the group.
Correct Answer: B
Rationale: nurse should maintain contact with client but not make demands to communicate or participate in activities
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An elderly client receiving IV fluids of 0.9% NaCl at 125 cc/h into her left arm. During a routine assessment, the nurse finds that the client has distended neck veins, shortness of breath, and crackles in both lung bases.
The nurse should
- A. decrease the IV rate to 20 cc/h and notify the physician.
- B. decrease the IV rate to 100 cc/h and continue to monitor the client.
- C. discontinue the IV and start oxygen at 6 L/min.
- D. assess for infiltration of the IV solution.
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate? No. Determine the outcome of each implementation. (1) correct-KVO (20 cc/h) will keep access open (2) need to notify physician, rate still too much since patient is in fluid overload (3) IV line may be necessary, diuretics may be ordered (4) description indicates circulatory overload, not infiltration
The nurse is caring for a client with a history of congestive heart failure (CHF). Which of the following findings would indicate to the nurse that the client's condition is worsening?
- A. Clear lung sounds bilaterally.
- B. Weight gain of 2 pounds in 24 hours.
- C. Urine output of 1,200 mL in 24 hours.
- D. Heart rate of 88 beats per minute.
Correct Answer: B
Rationale: weight gain is a sign of fluid retention, indicating worsening CHF
A 22-year-old mother of a 4-year-old boy comes to the antepartal clinic. Her second pregnancy has just been confirmed.
During this initial visit, it MOST important for the nurse to
- A. assess the client's feelings about pregnancy, labor, and delivery.
- B. obtain a history of the client's last labor and delivery.
- C. determine how the client's 4-year-old feels about the pregnancy.
- D. identify the client's general health needs.
Correct Answer: D
Rationale: Strategy: Think about each answer choice. (1) important data, priority is the here and now (2) important data, but not priority for first visit (3) important data, need to deal with the mother's needs first (4) correct-optimal opportunity for preventative health maintenance
A four-week-old infant with symptoms of pyloric stenosis is brought to the outpatient clinic by his mother. Which of the following statements would the nurse expect the mother to make about her son's symptoms?
- A. My son's bowel movements have turned black and sticky.
- B. I really have to encourage my son to suck the bottle.
- C. My son is fussy and seems hungry all the time.
- D. My son spits up green liquid after feeding.
Correct Answer: C
Rationale: becomes lethargic, dehydrated, and malnourished
Which of the following nursing actions has the HIGHEST priority for a teenager admitted with burns to 50% of his body?
- A. Counseling regarding problems of body image.
- B. Maintain airborne precautions.
- C. Maintain aseptic technique during procedures.
- D. Encourage peers to visit on a regular basis.
Correct Answer: C
Rationale: A teenager with 50% body burns is at high risk for infection due to loss of skin barrier. Maintaining aseptic technique during procedures is the highest priority to prevent life-threatening infections. Counseling, precautions, and peer visits are important but secondary to infection control.