Nokea
The nurse is evaluating the health status of an older client. Which finding is most important for the nurse to report to the healthcare provider?
- A. Client reports decreased urine output
- B. Client reports loss of appetite
- C. Client reports pain in the lower back
- D. Client reports a persistent cough
Correct Answer: C
Rationale: The correct answer is C because pain in the lower back may indicate a potential serious issue such as kidney problems or infection in the elderly. The kidneys are located in the lower back region, so pain in this area could be a sign of kidney dysfunction. The nurse should report this finding to the healthcare provider immediately for further evaluation and intervention.
Choice A is incorrect because decreased urine output can be a common issue in older adults and may not always indicate a serious problem. Choice B is incorrect as loss of appetite can have various causes and may not be as urgent as lower back pain. Choice D is also incorrect as a persistent cough can have multiple causes, but it is not as concerning as potential kidney issues indicated by lower back pain in an older client.
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A client who has a flaccid bladder is placed on a bladder training program. Which instruction should the nurse include in this client's teaching plan?
- A. Use manual pressure to express urine
- B. Perform the Crede maneuver
- C. Apply an external urinary drainage device
- D. Take a warm sitz bath twice a day
Correct Answer: B
Rationale: The correct answer is B: Perform the Crede maneuver. This is the appropriate instruction for a client with a flaccid bladder on a bladder training program. The Crede maneuver involves applying manual pressure on the bladder to assist with urine elimination. This technique helps to promote bladder emptying and prevent urinary retention.
A: Using manual pressure to express urine is not recommended as it can lead to urinary tract infections and damage to the bladder.
C: Applying an external urinary drainage device is not part of bladder training and does not address the issue of bladder emptying.
D: Taking a warm sitz bath twice a day does not directly address the client's flaccid bladder and is not a component of bladder training.
A client with a history of congestive heart failure (CHF) is admitted with fluid volume overload. Which assessment finding should the nurse report to the healthcare provider?
- A. Weight gain of 2 pounds in 24 hours
- B. Presence of a cough
- C. Edema in the lower extremities
- D. Shortness of breath
Correct Answer: D
Rationale: The correct answer is D: Shortness of breath. This assessment finding is crucial in a client with CHF and fluid volume overload as it indicates potential worsening of heart failure leading to pulmonary congestion. Shortness of breath is a common symptom of fluid accumulation in the lungs, requiring immediate intervention to prevent respiratory distress.
A: Weight gain of 2 pounds in 24 hours may indicate fluid retention but is not as urgent as shortness of breath.
B: Presence of a cough can be a symptom of CHF but is not as specific or concerning as shortness of breath.
C: Edema in the lower extremities is also a common finding in CHF but does not directly signify acute respiratory compromise as shortness of breath does.
The nurse is caring for a client who is 2 days post-op following an abdominal hysterectomy. The client reports feeling something 'give way' in the incision site and there is a small amount of bowel protruding from the wound. What action should the nurse take first?
- A. Apply a sterile saline dressing to the wound
- B. Notify the healthcare provider
- C. Administer pain medication
- D. Cover the wound with an abdominal binder
Correct Answer: A
Rationale: The correct action for the nurse to take first is to apply a sterile saline dressing to the wound (Choice A). This is because the client's situation suggests an incisional dehiscence, which is a surgical complication requiring immediate attention to prevent infection and further complications. Applying a sterile saline dressing helps protect the exposed bowel from contamination and dehydration.
Notifying the healthcare provider (Choice B) is important, but immediate wound care is the priority to prevent complications. Administering pain medication (Choice C) can wait until after the wound is properly dressed and assessed. Covering the wound with an abdominal binder (Choice D) is not appropriate in this situation as it does not address the urgent need to protect the exposed bowel and prevent infection.
The nurse is making assignments for a new graduate from a practical nursing program who is orienting to the unit. Because the unit is particularly busy this day, there will be little time to provide supervision of this new employee. Which client is the best for the nurse to assign to this newly graduated practical nurse?
- A. Whose discharge has been delayed because of a postoperative infection
- B. With poorly controlled type 2 diabetes who is on a sliding scale for insulin administration
- C. Newly admitted with a head injury who requires frequent assessments
- D. Receiving IV heparin that is regulated based on protocol
Correct Answer: A
Rationale: The correct answer is A: Whose discharge has been delayed because of a postoperative infection. This assignment is the best choice for the new graduate nurse because a client whose discharge has been delayed due to a postoperative infection is likely stable and requires minimal immediate interventions. This client would benefit from the new nurse's routine care and monitoring skills, allowing the nurse to focus on completing tasks efficiently.
Option B: With poorly controlled type 2 diabetes who is on a sliding scale for insulin administration requires close monitoring and frequent adjustments in insulin dosages, which may be challenging for a new nurse without adequate supervision.
Option C: Newly admitted with a head injury who requires frequent assessments demands critical thinking skills and quick decision-making abilities, which may overwhelm a new nurse who lacks experience in handling such cases.
Option D: Receiving IV heparin that is regulated based on protocol involves complex medication management and monitoring for potential complications, which may be beyond the scope of a new nurse's comfort level without proper guidance.
The nurse-manager of a perinatal unit is notified that one client from the medical-surgical unit needs to be transferred to make room for new admissions. Which client should the nurse recommend for transfer to the antepartal unit?
- A. A 45-year-old with chronic hepatitis B.
- B. A 35-year-old with lupus erythematosus
- C. A 19-year-old diagnosed with rubella
- D. A 25-year-old with herpes lesions of the vulva
Correct Answer: B
Rationale: The correct answer is B: A 35-year-old with lupus erythematosus. This client should be recommended for transfer to the antepartal unit because lupus erythematosus is an autoimmune disorder that can affect pregnancy outcomes. The antepartal unit is better equipped to provide specialized care for high-risk pregnancies, which would be necessary for a client with lupus.
A: A 45-year-old with chronic hepatitis B - Hepatitis B does not directly impact pregnancy outcomes and does not require transfer to the antepartal unit.
C: A 19-year-old diagnosed with rubella - Rubella is a viral infection that can be harmful during pregnancy, but the client should be managed in a different unit specialized in infectious diseases.
D: A 25-year-old with herpes lesions of the vulva - Herpes lesions of the vulva can be managed in the medical-surgical unit and do not necessarily require transfer to the antepartal unit unless there