Nokea
The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?
- A. The client's blood pressure reading will be less than 160/90 mm Hg.
- B. The client's daily blood pressure will be less than 140/80 mm Hg this month.
- C. The client's family will repeat signs and symptoms about the disease.
- D. The nurse will encourage the client to walk thirty minutes every day.
Correct Answer: B
Rationale: A blood pressure goal of less than 140/80 mm Hg is specific and aligns with cardiovascular health targets, addressing blurred vision linked to hypertension.
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A client with bilateral carpal tunnel syndrome reports to the nurse that the pain and tingling experienced worsens at night. Which client teaching should the nurse provide?
- A. Notify the healthcare provider as soon as possible.
- B. Wear braces on both wrists during the night.
- C. Elevate the hands on two pillows at night.
- D. Apply cold compresses for 30 minutes before bedtime.
Correct Answer: B
Rationale: Wrist braces maintain a neutral position, reducing median nerve pressure and alleviating nighttime symptoms.
The practical nurse (PN) is assisting in a community center clinic when four clients simultaneously arrive seeking help. In which order should the PN prioritize care to be provided based on the client needs? (Arrange the client with the highest priority first, on top, and lowest priority last, on bottom.)
- A. A 12-year-old child with history of asthma who is wheezing and complaining of shortness of breath.
- B. A 7-year-old child who has type 1 diabetes mellitus and is experiencing extreme hunger and shakiness
- C. A 10-year-old child with bleeding lacerations on both knees after falling on the playground
- D. A 5-year-old child who is crying uncontrollably because of an incontinent bowel episode.
Correct Answer: A,B,C,D
Rationale: Prioritization is based on the urgency and potential life-threatening nature of the conditions. The asthma attack is the highest priority due to potential airway compromise. Hypoglycemia is next due to the risk of neurological complications. Bleeding lacerations pose a risk of infection and blood loss, and the incontinent episode is primarily psychosocial, making it the lowest priority.
The nurse is caring for a client who is receiving teletherapy radiation for a malignant tumor. Which Instruction regarding skin care of the portal site should the nurse provide?
- A. Remove the ink marks of the portal after each radiation treatment.
- B. Protect the skin of the radiation portal site from sunlight exposure.
- C. Apply moisture lotions daily to the radiation portal site.
- D. Avoid washing the skin inside the radiation portal site.
Correct Answer: B
Rationale: Protecting the portal site from sunlight prevents exacerbated skin reactions during radiation therapy.
Orders
Laboratory Results
Day 1, 1000
Serum uric acid, blood urea nitrogen (BUN), creatinine (Cr)
X-ray of right foot
Day 1, 1015
Acetaminophen 650 mg PO now
Based on the client's laboratory findings, the nurse recognizes that the client is having an acute gout attack and is most at risk for SwellingBruisingInfectionInflammationRash and DiscolorationErythemaCyanosisPallorEcchymosis in his affected joint.
- A. Inflammation
- B. Discoloration
- C. Erythema Cyanosis
- D. Swelling
- E. Bruising
Correct Answer: A,B
Rationale: Inflammation and discoloration are hallmark symptoms of gout due to urate crystal-induced immune response and increased blood flow.
A client arrives to the medical-surgical unit 4 hours after a transurethral resection of the prostate (TURP). A triple-lumen catheter for continuous bladder irrigation with 0.9% sodium chloride is infusing and the nurse observes dark, pink-tinged outflow with blood clots in the tubing and collection bag. Which action should the nurse take?
- A. Decrease the flow rate.
- B. Irrigate the catheter manually.
- C. Discontinue infusing solution.
- D. Monitor catheter drainage.
Correct Answer: B
Rationale: Manual irrigation clears clots, maintaining catheter patency and preventing obstruction post-TURP.