Nokea
The nurse is caring for clients on a medical/surgical unit and determines that several situations need to be addressed.
- A. Which situation should the nurse attend to first?
- B. An angry daughter is threatening to sue the hospital because her confused mother fell out of bed during the previous shift.
- C. The nursing assistant is 30 minutes overdue from a dinner break in the cafeteria for the third time this week.
- D. The physician calls the unit to ask the nurse to obtain a client’s laTest serum electrolyte results from the lab.
- E. The husband of a client reports to the nurse that his wife’s nose began bleeding after she returned from radiation therapy.
Correct Answer: D
Rationale: A nosebleed post-radiation therapy is the least stable situation, as it may indicate a serious complication like thrombocytopenia or tissue damage, requiring immediate assessment. Legal threats, staff issues, and lab result requests are less urgent than a potentially life-threatening condition.
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A child in the waiting room who can walk up and down steps, has a steady gait, can stand on one foot momentarily, and jumps with both feet.
The nurse identifies the child's chronological age to be
- A. 1 year old.
- B. 2 years old.
- C. 3 years old.
- D. 5 years old.
Correct Answer: C
Rationale: Strategy: Picture the child at each age. (1) unable to walk up and down stairs with hand held until 18 months (2) unable to jump until 30 months (3) correct-able to jump with both feet and stand on one foot momentarily at 30 months (4) behaviors are seen in younger child
A client's blood gasses are as follows: pH=7.32, pCO2=62, HCO3=30, and pO2=62. The best interpretation is that the client has which of the following?
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct Answer: A
Rationale: Low pH and high pCO2 indicate respiratory acidosis, likely from CO2 retention, with HCO3 compensating.
An adult had exploratory surgery and postoperatively had an exacerbation of asthma. The client is on a rebreathing mask and seems upset and angry. What is the best nursing approach?
- A. Ask the physician for an order for lorazepam (Ativan).
- B. Spend some time with the client.
- C. Ask the family to have someone stay with the client.
- D. Apply wrist restraints.
Correct Answer: B
Rationale: Spending time with the client addresses emotional distress, calming them without medication or restraints, supporting asthma management.
A patient several days after an above-knee amputation (AKA).
Which of the following symptoms would be characteristic of an infected stump wound?
- A. The patient is anxious and restless.
- B. There is a small amount of dark drainage on the dressing.
- C. The patient complains of persistent pain at the operative site.
- D. The skin is cool above the operative site.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to an infected wound. (1) may be due to changes in body image or pain (2) expected, not indicative of an infection (3) correct-pain is characteristic of inflammation and infection (4) warm skin above site would indicate infection
The nurse is developing a care plan for a client with severe anxiety. An appropriate outcome for the client is that within 4 days the client should:
- A. Have decreased anxiety.
- B. Talk to the nurse for 10 minutes.
- C. Sit quietly for 30 minutes.
- D. Develop an adaptive coping mechanism.
Correct Answer: B
Rationale: Outcome criteria need to be specific, measurable, and realistic. Talking for 10 minutes meets all of these conditions.