Nokea
The nurse is caring for clients in the skilled nursing facility.
- A. Which client requires the nurse’s immediate attention?
- B. A client admitted for a cerebral vascular accident (CVA) whose prescription for warfarin (Coumadin) expired two days ago.
- C. A client in pain who was receiving morphine in an acute care institution and was transferred with a prescription for acetaminophen with codeine.
- D. A client who has dysuria and foul-smelling, cloudy, dark amber urine.
- E. An immunosuppressed client who has not received an influenza immunization.
Correct Answer: A
Rationale: A client with an expired warfarin prescription post-CVA is at high risk for recurrent stroke due to the anticoagulant’s 2-5 day duration, requiring immediate attention. Pain management, urinary symptoms, and immunization are less urgent.
You may also like to solve these questions
The physician orders meperidine (Demerol) 50 mg IM every 3-4 h PRN for pain for a client. The client asks the nurse for the medication at bedtime. Prior to administering the pain medication, the nurse should
- A. take measures to determine if the pain is psychological.
- B. check to see if the man has a history of addiction.
- C. try several other comfort and pain relief measures.
- D. learn the location, character, and intensity of the pain.
Correct Answer: D
Rationale: assessment first step in nursing process
The nurse is caring for a client with a history of congestive heart failure.
- A. Which instruction is most important for a client with congestive heart failure?
- B. Weigh yourself daily at the same time.
- C. Take extra diuretics if you feel short of breath.
- D. Eat a high-sodium diet to maintain electrolytes.
- E. Avoid exercise to prevent cardiac strain.
Correct Answer: A
Rationale: Daily weight monitoring detects fluid retention early, a key indicator of worsening heart failure. Extra diuretics require medical orders, high-sodium diets worsen fluid retention, and exercise is encouraged within limits.
The home care nurse instructs the wife of a client about how to perform a wet-to-dry abdominal dressing for her husband with an infected abdominal incision. The nurse should intervene in which of the following situations?
- A. The wife wets the old dressing with sterile saline before removing it.
- B. The wife covers the wound with wet, sterile 4 × 4s.
- C. The wife irrigates the wound with hydrogen peroxide using a bulb syringe.
- D. The wife uses Montgomery straps to secure the dressing.
Correct Answer: A
Rationale: contraindicated, remove dry so wound debris and necrotic tissue are removed with old dressing
A client who has just indicated a wish to kill herself and asks the nurse not to tell anyone.
The nurse's BEST response should be to
- A. encourage the client not to do anything without thinking it through very carefully.
- B. explain to the client that anything she tells the nurse is kept strictly confidential.
- C. report this to staff members in order to protect the client.
- D. encourage the client to tell the nurse more about what she is feeling.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) does not answer client's immediate concern or give client accurate information about what the nurse will do (2) does not answer client's immediate concern or give client accurate information about what the nurse will do (3) correct-nurse must let the client know that this information will be shared with the staff so that the client's safety can be preserved (4) does not answer client's immediate concern or give client accurate information about what the nurse will do
The mother of a seven-year-old child is dying.
The nurse should anticipate that the seven-year-old child would have which of the following concepts of death?
- A. Death is punishment for his/her actions.
- B. Death is inevitable and irreversible.
- C. Death is temporary and gradual.
- D. Death as a concept based on past experience.
Correct Answer: A
Rationale: Strategy: Remember growth and development. (1) correct-seven-year-olds see death as a punishment (2) by age of 9, most children begin to develop an adult concept of death and begin to understand that death is irreversible (3) is a preschool child's concept of death (4) is an adolescent's concept of death