Nokea
The nurse is doing hourly rounds when he finds a 73-year-old female client unconscious on the floor next to the bed. An incident report must be filled out. What is the best statement for the nurse to write on the incident report?
- A. Client fell out of bed at some point between 0700 and 0800.'
- B. Client was found unresponsive on floor next to the bed.'
- C. Client likely slipped on the floor and hit her head.'
- D. Client attempted to ambulate without assistance and fell.'
Correct Answer: B
Rationale: The incident report should state objective findings: 'Client was found unresponsive on floor next to the bed.' Speculative statements (slipped, attempted to ambulate) are inappropriate.
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A client is admitted with suspected abdominal aortic aneurysm (AAA). A common complaint of the client with an abdominal aortic aneurysm is:
- A. Loss of sensation in the lower extremities
- B. Back pain that lessens when standing
- C. Decreased urinary output
- D. Pulsations in the periumbilical area
Correct Answer: D
Rationale: A pulsatile mass in the periumbilical area is a classic symptom of an abdominal aortic aneurysm due to the expanding aorta.
The nurse is assessing an ECG strip of a 42-year-old client and finds a regular rate greater than 100, a normal QRS complex, a normal P wave in front of each QRS, a PR interval between 0.12 and 0.20 seconds, and a P: QRS ratio of 1:1. What is the nurse's interpretation of this rhythm?
- A. Premature atrial complex
- B. Sinus tachycardia
- C. Atrial flutter
- D. Supraventricular tachycardia
Correct Answer: B
Rationale: A regular rate >100 with normal P waves, QRS complexes, and PR interval indicates sinus tachycardia, a common response to stress, fever, or hypoxia.
A client in labor has been given epidural anesthesia with Marcaine (bupivacaine). To reverse the hypotension associated with epidural anesthesia, the nurse should have which medication available?
- A. Narcan (naloxone)
- B. Dobutrex (dobutamine)
- C. Romazicon (flumazenil)
- D. Adrenalin (epinephrine)
Correct Answer: D
Rationale: Epinephrine is used to treat hypotension from epidural anesthesia by increasing blood pressure through vasoconstriction and cardiac stimulation.
The nurse is caring for a client with documented severe allergies to latex. Which item on the client's meal tray should the nurse remove?
- A. a banana
- B. a bowl of beef broth
- C. a vanilla pudding cup
- D. a cup of strawberries
Correct Answer: A
Rationale: Bananas can cause a cross-reaction in latex-allergic clients due to shared proteins (latex-fruit syndrome). Other items are safe.
The nurse is caring for a client receiving peritoneal dialysis. Which of the following assessment findings would require an intervention by the nurse?
- A. Abdominal discomfort during infusion of dialysate.
- B. Presence of constipation.
- C. Cloudy dialysate output.
- D. Ecchymosis around peritoneal catheter.
Correct Answer: C
Rationale: indicates peritonitis, also will see nausea and vomiting, anorexia, abdominal pain, tenderness, rigidity