Nokea
The nurse is conducting a physical assessment. The data the nurse would collect vary depending on what?
- A. How much time the nurse has
- B. The client's acuity
- C. The client's cooperation
- D. Onset of current symptoms
Correct Answer: B
Rationale: Step 1: The nurse should prioritize collecting data based on the client's acuity to address immediate needs and ensure patient safety.
Step 2: Acuity determines the urgency and intensity of care required, guiding the assessment focus.
Step 3: Time available or client cooperation may influence the depth of assessment but do not dictate the data collected.
Step 4: The onset of symptoms is important for history-taking but not the primary factor in determining assessment data.
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What is the most important assessment for a client who has been receiving chemotherapy for several weeks?
- A. Check for signs of infection
- B. Monitor the client's weight
- C. Monitor the client's nutrition
- D. Check for skin changes
Correct Answer: A
Rationale: The correct answer is A: Check for signs of infection. This is crucial because chemotherapy weakens the immune system, increasing the risk of infections. Signs of infection such as fever, chills, sore throat, and cough should be closely monitored to prevent serious complications. Monitoring weight (B) and nutrition (C) are important but not as critical as detecting infections promptly. Checking for skin changes (D) is also important, but it is secondary to identifying and managing infections due to the immediate threat they pose to the client's health.
What is the most appropriate action for a client with a history of asthma who is experiencing wheezing?
- A. Administer albuterol
- B. Administer antihistamines
- C. Monitor for signs of infection
- D. Administer epinephrine
Correct Answer: A
Rationale: The correct answer is A: Administer albuterol. Albuterol is a bronchodilator that helps open the airways, relieving wheezing in asthma patients. It is the first-line treatment for acute asthma exacerbations. Antihistamines (B) do not treat asthma symptoms. Monitoring for infection (C) is important but not the immediate action for wheezing. Epinephrine (D) is used for severe allergic reactions, not routine asthma management.
What should be the nurse's first action for a client with a suspected myocardial infarction (MI)?
- A. Administer nitroglycerin
- B. Monitor cardiac rhythm
- C. Assess the ECG
- D. Assist with positioning
Correct Answer: A
Rationale: The correct answer is A: Administer nitroglycerin. This is the nurse's first action for a client with a suspected MI because nitroglycerin helps dilate blood vessels, improving blood flow to the heart. This can help reduce chest pain and prevent further damage to the heart muscle. Administering nitroglycerin promptly is crucial in managing an MI. Monitoring cardiac rhythm (B) and assessing the ECG (C) are important steps, but administering nitroglycerin takes precedence in addressing the client's immediate symptoms. Assisting with positioning (D) is not as urgent or directly related to managing an MI compared to administering nitroglycerin.
A 59-year-old patient tells the nurse that he is in the clinic to "check up on his ulcerative colitis." He has been having "black stools" in the last 24 hours. How would the nurse document his reason for seeking care?
- A. J.M. is a 59-year-old male here for "ulcerative colitis."
- B. J.M. came into the clinic complaining of black stools in the past 24 hours.
- C. J.M., a 59-year-old male, states he has ulcerative colitis and wants to have it checked up.
- D. J.M. is a 59-year-old male here for having "black stools" in the past 24 hours.
Correct Answer: D
Rationale: The correct answer is D because it accurately reflects the patient's chief complaint of having black stools in the last 24 hours, which is a concerning symptom suggestive of gastrointestinal bleeding. This documentation is specific and focused on the reason for seeking care, prioritizing the urgent nature of the symptom.
Choice A is incorrect because it does not mention the presenting symptom of black stools. Choice B is incorrect as it does not directly state the reason for seeking care. Choice C is incorrect as it focuses on the patient's self-diagnosis of ulcerative colitis rather than the current concerning symptom of black stools.
A patient with chronic kidney disease (CKD) is being assessed. The nurse would expect to find which of the following symptoms?
- A. Weight loss and polyphagia.
- B. Edema and proteinuria.
- C. Hypertension and tachycardia.
- D. Hypothermia and bradycardia.
Correct Answer: B
Rationale: The correct answer is B: Edema and proteinuria. In CKD, the kidneys are unable to filter waste products effectively, leading to fluid retention (edema) and protein leaking into the urine (proteinuria). Edema occurs due to fluid buildup from decreased kidney function. Proteinuria is a result of damaged glomeruli in the kidneys, allowing proteins to leak into the urine. Weight loss and polyphagia (excessive hunger) are not typical symptoms of CKD. Hypertension and tachycardia can occur in CKD due to fluid overload and electrolyte imbalances. Hypothermia and bradycardia are not common symptoms of CKD and would be more indicative of other conditions.