Nokea
The nurse is caring for assigned clients. The nurse should first check the client
- A. with hypothyroidism who is reporting constipation, weakness, and peripheral edema
- B. with chronic pancreatitis who is reporting upper abdominal pain and voluminous, foul-smelling, fatty stools
- C. who has bacterial pneumonia, is receiving IV antibiotic therapy, and is reporting a cough productive of blood-tinged sputum
- D. who has an external fixation device, a temperature of 101.8°F (38.8°C), and is reporting redness and pain around the pin sites
Correct Answer: D
Rationale: Fever, redness, and pain around pin sites suggest a possible infection at the external fixation site, which is a priority due to the risk of osteomyelitis or systemic infection.
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The nurse is conducting a home visit to assess an elderly client with advanced heart failure who lives alone. When the nurse asks about sodium intake, the client becomes angry and says, 'I'm so tired of people telling me what to do! I'm going to eat what I want, so leave me alone!' Which of the following is the most appropriate response by the nurse?
- A. I can tell that you want me to go, so I will call in a few days to see how you are doing.
- B. I know you are frustrated with losing control of your life.
- C. It sounds like you are angry. Tell me what's bothering you.
- D. Okay. I'll just check your blood pressure and then go.
Correct Answer: C
Rationale: Acknowledging the client's anger and inviting them to express their feelings promotes therapeutic communication, helping to de-escalate the situation and address underlying concerns.
The nurse is walking through a crowded waiting room when the respiratory therapist approaches the nurse and asks, 'How is the client in room 312?' Which of the following responses would be most appropriate for the nurse to make?
- A. I will document my most recent assessment in the client's medical record for your review.
- B. Additional medications were prescribed to help improve the client's respiratory status.
- C. The client was doing much better when I last checked during hourly rounds.
- D. We need to move away from this area to discuss the client's status.
Correct Answer: D
Rationale: Discussing client information in a crowded area risks breaching confidentiality. Moving to a private area ensures compliance with HIPAA and protects client privacy.
The nurse is caring for a client after a motor vehicle accident. The client's injuries include 2 fractured ribs and a concussion. The nurse notes which findings as expected neurological changes for the client with a concussion? Select all that apply.
- A. Amnesia
- B. Asymmetrical pupillary constriction
- C. Brief loss of consciousness
- D. Headache
- E. Loss of vision
Correct Answer: A,C,D
Rationale: Amnesia (A), brief loss of consciousness (C), and headache (D) are common symptoms of concussion due to temporary brain dysfunction.
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.
A victim of domestic violence tells the batterer she needs a little time away. How would the nurse expect that the batterer might respond?
- A. With acceptance and views the victim's comment as an indication that their marriage is in trouble
- B. With fear of rejection causing increased rage toward the victim
- C. With a new commitment to seek counseling to assist with their marital problems
- D. With relief, and welcomes the separation as a means to have some personal time
Correct Answer: B
Rationale: With fear of rejection causing increased rage toward the victim. Fear of abandonment often escalates abusive behavior.