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The nurse is discussing how to prioritize care with the UAP. Which client should the nurse instruct the UAP to see first?
- A. The immobile client who needs sequential compression devices removed.
- B. The elderly woman who needs assistance ambulating to the bathroom.
- C. The surgical client who needs help changing the gown after bathing.
- D. The male client who needs the intravenous catheter discontinued.
Correct Answer: B
Rationale: Assisting an elderly woman to the bathroom prevents falls and addresses immediate elimination needs, prioritizing safety. Removing SCDs, changing gowns, and discontinuing IVs are less urgent.
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Which assessment supports the nurse's assumption that the client's sleep disturbance was most likely due to anxiety?
- A. The client was pacing the room before bedtime.
- B. The client's vital signs were stable during the night.
- C. The client requested a sleeping pill earlier.
- D. The client reported feeling rested in the morning.
Correct Answer: A
Rationale: Pacing before bedtime is a behavioral sign of anxiety, supporting the assumption that anxiety caused the sleep disturbance.
The elderly client being seen in the clinic has complaints of urinary frequency, urgency, and 'leaking.' Which priority intervention should the nurse implement when interviewing the client?
- A. Ensure communication is nonjudgmental and respectful.
- B. Set the temperature for comfort in the examination room.
- C. Speak loudly to ensure the client understands the nurse.
- D. Ensure the examining room has adequate lighting.
Correct Answer: A
Rationale: Nonjudgmental, respectful communication builds trust, encouraging the elderly client to discuss sensitive incontinence issues openly. Comfort, loud speech, and lighting are secondary to effective communication.
Which clinical manifestations should the nurse expect to assess for the client diagnosed with a ureteral renal stone?
- A. Dull, aching flank pain and microscopic hematuria.
- B. Nausea; vomiting; pallor; and cool, clammy skin.
- C. Gross hematuria and dull suprapubic pain with voiding.
- D. The client will be asymptomatic.
Correct Answer: B
Rationale: Ureteral stones cause severe colicky pain, often with nausea, vomiting, pallor, and diaphoresis due to autonomic response. Flank pain and microscopic hematuria are more typical of renal pelvic stones, gross hematuria is less common, and stones are rarely asymptomatic.
The nurse is preparing the discharge teaching plan for the male client with a left-sided nephrectomy. Which statement indicates the teaching is effective?
- A. I can’t wait to start back to work next week, I really need the money.
- B. I will take my temperature and if it is above 101 I will call my doctor.
- C. I am glad I won’t have to keep track of how much I urinate in the day.
- D. I am happy I will be able eat what I usually eat, I don’t like this food.
Correct Answer: B
Rationale: Effective discharge teaching post-nephrectomy includes recognizing signs of infection, such as fever above 101°F, requiring prompt reporting. Returning to work too soon, not monitoring urine output, or resuming a normal diet may be incorrect.
While the fluid is being administered, which nursing assessment is most important?
- A. Checking for pedal edema
- B. Assessing the rapid weight gain
- C. Monitoring specific gravity
- D. Auscultating breath sounds
Correct Answer: D
Rationale: Auscultating breath sounds is critical during a fluid challenge to detect signs of fluid overload, such as pulmonary edema.