Nokea
The nurse is caring for clients on the neurology unit.
- A. What is the most appropriate action for the nurse to take after noting a client suddenly developed a fixed and dilated pupil?
- B. Reassess in five minutes.
- C. Check the client’s visual acuity.
- D. Lower the head of the client’s bed.
- E. Contact the physician.
Correct Answer: D
Rationale: A fixed and dilated pupil is a neurological emergency, often indicating increased intracranial pressure or brain herniation. Immediate physician notification is critical to initiate interventions. Reassessing later delays care, checking visual acuity is irrelevant, and lowering the bed could worsen intracranial pressure.
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The nurse is caring for a client with a history of type 2 diabetes who is receiving exenatide (Byetta) 10 mcg SC bid. Which of the following symptoms should the nurse report immediately?
- A. Mild nausea
- B. Upper abdominal pain
- C. Occasional thirst
- D. Mild fatigue
Correct Answer: B
Rationale: Upper abdominal pain may indicate pancreatitis, a serious exenatide side effect. Options A, C, and D are less urgent: nausea is common, thirst is expected, and fatigue is nonspecific.
The nurse is caring for a client who is postoperative day 1 after a mastectomy. Which of the following actions is the PRIORITY?
- A. Encourage the client to perform arm exercises.
- B. Administer pain medication as needed.
- C. Monitor the surgical drain for output.
- D. Check the incision for redness.
Correct Answer: A
Rationale: Encouraging arm exercises is the priority to prevent lymphedema and restore mobility post-mastectomy. Options B, C, and D are important but secondary: pain management, drain monitoring, and incision checks follow mobility promotion.
The nurse has just returned to the desk and has four phone messages to return.
Which of the following messages should the nurse return FIRST?
- A. A man with swelling of his left wrist following a fall from a ladder two hours ago.
- B. A woman who had a cholecystectomy one week ago and now complains of redness and tenderness at the incision site.
- C. A mother of a child reports that her son's lips are swollen following a fire ant bite.
- D. A man with COPD reports he is coughing up large amounts of green-tinged sputum and has a temperature of 101.2°F (38.4°C).
Correct Answer: C
Rationale: Strategy: Remember the ABCs. (1) wrist needs to be x-rayed, not a priority (2) indicates infection, treated with antibiotic (3) correct-potential anaphylactic reaction, administer epinephrine, corticosteroids; treat for shock (4) indicates infection, treat with an antibiotic
The nurse is teaching a client with a new diagnosis of hyperthyroidism about methimazole (Tapazole). Which of the following statements by the client indicates a need for further teaching?
- A. I should report a sore throat to my doctor.
- B. I should take this medication with food.
- C. I should avoid eating iodized salt.
- D. I should stop this medication if I feel better.
Correct Answer: D
Rationale: Stopping methimazole when feeling better is incorrect, as hyperthyroidism requires prolonged treatment to achieve euthyroid status. Options A, B, and C are correct: sore throat may indicate agranulocytosis, food reduces GI upset, and avoiding iodized salt prevents thyroid stimulation.
The nurse evaluates the nutritional intake of a 16-year-old girl at a camp for adolescents. The girl eats all of the food provided to her at the camp cafeteria. Each of the day's three meals contains foods from all areas of the food pyramid, and each meal averages about 900 calories and 3 mg of iron. The girl has been menstruating monthly for about two years. Which of the following descriptions, if made by the nurse, BEST describes the girl's intake if her weight is appropriate for her height?
- A. Her diet is low in calories and high in iron.
- B. Her diet is low in calories and low in iron.
- C. Her diet is high in calories and low in iron.
- D. Her diet is high in calories and high in iron.
Correct Answer: C
Rationale: 900 × 3 = 2,700 calories/day and women need 1,200-1,500 kcal/day (men need 1,500-1,800 kcal/day); 3 mg × 3 = 9 mg/day of iron and women need 15 mg/day of iron (men need 10 mg/day); with pregnancy 30 mg/day required