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The nurse is having difficulty reading the healthcare provider's written order that was written right before the shift change. What action should be taken?
- A. Leave the order for the oncoming staff to follow up
- B. Contact the charge nurse for an interpretation
- C. Ask the pharmacy for assistance in interpretation
- D. Call the provider for clarification
Correct Answer: D
Rationale: The nurse should call the provider for clarification. In situations where there is difficulty reading an order, it is crucial to directly contact the healthcare provider to ensure the correct order is understood and followed. Leaving the order for the oncoming staff (Choice A) may lead to misunderstandings and errors. Contacting the charge nurse (Choice B) may cause delays as they may also need to contact the provider. Asking the pharmacy (Choice C) is not the most direct and immediate action in this scenario, as the provider is the one who can provide immediate clarification.
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The nurse is caring for a client diagnosed with hypothyroidism. Which finding should the nurse expect to observe?
- A. Weight gain
- B. Heat intolerance
- C. Increased appetite
- D. Frequent diarrhea
Correct Answer: A
Rationale: The correct answer is weight gain. In hypothyroidism, there is a decrease in metabolic rate, which can lead to weight gain. Heat intolerance (choice B) is more commonly associated with hyperthyroidism. Increased appetite (choice C) and frequent diarrhea (choice D) are not typical findings in hypothyroidism. Therefore, choices B, C, and D are incorrect.
A client with Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?
- A. Comatose, breathing unlabored
- B. Glasgow Coma Scale 8, respirations regular
- C. Appears to be sleeping, vital signs stable
- D. Glasgow Coma Scale 13, no ventilator required
Correct Answer: B
Rationale: The correct answer is B: 'Glasgow Coma Scale 8, respirations regular.' A Glasgow Coma Scale of 8 with regular respirations accurately describes a non-responsive state with independent breathing. Choice A is incorrect because 'comatose' implies a deep state of unconsciousness, which may not be accurate in this case. Choice C is incorrect as stating the client 'appears to be sleeping' may not accurately reflect the severity of the situation. Choice D is incorrect because a Glasgow Coma Scale of 13 would not typically correspond to a non-responsive state.
The female is caring for a male patient who is uncircumcised but not ambulatory and has full function of all extremities. The nurse is providing the patient with a partial bed bath. How should perineal care be performed for this patient?
- A. Should be postponed because it may cause embarrassment.
- B. Should be unnecessary because the patient is uncircumcised.
- C. Should be done by the patient.
- D. Should be done by the nurse.
Correct Answer: C
Rationale: Perineal care should be encouraged to be done by the patient if they are capable of performing self-care. In this scenario, the patient is not ambulatory and has full function of all extremities, indicating that the patient can independently perform perineal care. Encouraging self-care promotes independence and maintains the patient's dignity. Postponing perineal care (Choice A) is incorrect because it is essential for hygiene. Choice B is incorrect as perineal care is necessary for all patients regardless of circumcision status. Choice D is incorrect as the patient is capable of performing the care independently, and promoting self-care is a priority in nursing practice.
While providing care to a group of patients, which patient should the nurse prioritize seeing first?
- A. A patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea
- B. A bedridden patient with a reddened area on the buttocks who needs to be turned
- C. A patient on bed rest with renal calculi who needs to go to the bathroom
- D. A patient post-knee surgery who needs range of motion exercises
Correct Answer: A
Rationale: The nurse should prioritize seeing the patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea first. This patient is at higher risk for deep vein thrombosis due to prolonged bed rest, which can lead to a life-threatening embolus. Chest pain and dyspnea could also indicate a potential pulmonary embolism, which requires immediate assessment and intervention. The other patients, while requiring care, do not present with symptoms that suggest an immediate life-threatening situation, making them lower priority at this time. Therefore, option A is the correct choice as it addresses a potentially critical condition that requires immediate attention.
A client has been on bed rest for several weeks. Which finding should the nurse identify as the priority during assessment?
- A. Musculoskeletal weakness
- B. Loss of appetite
- C. Increased heart rate during physical activity
- D. Left lower extremity tenderness
Correct Answer: D
Rationale: The nurse should prioritize assessing left lower extremity tenderness as it could indicate deep vein thrombosis, a serious condition that requires immediate attention. Musculoskeletal weakness, loss of appetite, and increased heart rate during physical activity are important but not as critical as a potential thrombotic event that could lead to life-threatening complications. Deep vein thrombosis is a common risk for individuals on prolonged bed rest due to reduced mobility and blood stasis.