Nokea
The nurse is caring for clients in the outpatient clinic. The nurse returns to the desk and finds four phone messages. Which of the following messages should the nurse return FIRST?
- A. A client with cold symptoms has an oral temperature of 103°F (39.4°C).
- B. A client with stage II decubitus ulcer reports that the dressing has come off.
- C. A client is nauseated and has vomited 6 times in the previous 24 hours.
- D. A client is complaining of leg pain after walking half a mile.
Correct Answer: C
Rationale: assess amount, character, symptoms of fluid volume deficit
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A 57-year-old man admitted with metastatic cancer has been receiving chemotherapy for 3 months. His lab values include: RBC 3.8 million/mm³, WBC 2,000/mm³, Hgb 9.3 g/dL, platelets 50,000/mm³. Which of the following nursing diagnoses is MOST appropriate for this patient?
- A. Decreased cardiac output.
- B. Ineffective thermoregulation.
- C. Risk for injury.
- D. Ineffective airway clearance.
Correct Answer: C
Rationale: due to low platelet count, normal platelets 150,000-400,000/mm³, decrease causes problems with blood clotting
The nurse in a long-term care facility is reviewing the nurse's notes in a client's chart. The nurse would be MOST concerned by which of the following entries?
- A. Foley catheter draining clear urine and the pH is 6.5.
- B. The client's skin is blanched over the scapular areas.
- C. Vital signs are within normal limits.
- D. The client drinks three glasses of orange juice every day.
Correct Answer: B
Rationale: blanching or hyperemia that does not disappear in a short time is a warning sign of pressure ulcers
The nurse is caring for a 74-year-old man with type I diabetes. The client is scheduled for cataract surgery under general anesthesia at 9 AM. The man usually receives 30 units of NPH and 10 units of regular insulin each morning at 7 AM. At 7 AM the morning of surgery, the nurse would expect to take which of the following actions?
- A. hold the morning dose of NPH and regular insulin and monitor the blood glucose.
- B. give half the morning dose of NPH insulin along with the regular insulin and monitor the blood glucose when the client returns from surgery.
- C. give the full dose of NPH and regular insulin and monitor the blood glucose every 2 to 4 hours.
- D. give the full dose of regular insulin but hold the NPH insulin and monitor the blood glucose until the client goes to surgery.
Correct Answer: A
Rationale: usually use sliding scale with regular insulin based on blood glucose readings
The nurse is caring for an 11-year-old girl being treated for a fractured right femur with balanced suspension traction with a Thomas ring and Pearson attachment. The physician orders 2 liters to be instilled with a dwell time of 40 minutes. The nurse measures the outflow and finds it to be 1,800 cc. During the nurse's shift, the client drinks 700 cc of fluids and voids 400 cc. The nurse should record which of the following on the client's intake and output sheet?
- A. Intake: 2,700 cc; output: 400 cc.
- B. Intake: 2,700 cc; output: 2,200 cc.
- C. Intake: 700 cc; output: 400 cc.
- D. Intake: 2,700 cc; output: 1,800 cc.
Correct Answer: B
Rationale: intake and output
The nurse is preparing to suction a client with a new tracheostomy in the postanesthesia recovery room. Which of the following actions, if performed by the nurse, indicates a break in proper technique?
- A. The nurse sets the suction source at 120 mm Hg and obtains a #14 French suction catheter.
- B. The nurse inserts the suction catheter until resistance is met, and then applies intermittent suction as the catheter is withdrawn.
- C. The nurse suctions the client's mouth prior to suctioning the tracheostomy to ensure a patent airway.
- D. The nurse administers oxygen to the client using an Ambu bag attached to 100% oxygen prior to suctioning.
Correct Answer: C
Rationale: break in sterile procedure, suction mouth after trachea