Nokea
The nurse is making assignments for the day. The staff consists of an RN, a novice RN, an LPN, and a nursing assistant. Which client should be assigned to the RN?
- A. A client with peptic ulcer disease
- B. A client with skeletal traction for a fractured femur
- C. A client with an abdominal cholecystectomy
- D. A client with an esophageal tamponade
Correct Answer: D
Rationale: The client with an esophageal tamponade requires complex monitoring and intervention, best suited for an experienced RN.
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A client has returned from surgery after removal of a tumor of the colon and creation of a temporary colostomy. She refuses to take a deep breath and cough then refuses to turn. Which of the following should the nurse assess first in trying to understand her lack of cooperation?
- A. Delirium status.
- B. Vital signs.
- C. Oxygen saturation.
- D. Level of pain.
Correct Answer: D
Rationale: Pain (D) is the most likely reason for refusing to cough or turn post-surgery, as these actions can exacerbate discomfort. Assessing pain first guides appropriate interventions. Delirium (A), vital signs (B), and oxygen saturation (C) are secondary.
When preparing a client for magnetic resonance imaging, the nurse should implement which of the following?
- A. Obtain informed consent and administer atropine 0.4 mg
- B. Scrub the injection site for 15 minutes
- C. Remove any jewelry and inquire about metal implants
- D. Administer Benadryl 50 mg/mL IV
Correct Answer: C
Rationale: MRI safety requires removing jewelry and screening for metal implants to prevent injury from magnetic fields. The other actions are unnecessary or incorrect.
A 19-year-old male was prescribed sertraline (Zoloft) 3 weeks ago for depression. He calls the clinic today and tells the nurse that he has been feeling increasingly anxious and wants to stop taking the medication because it is not working. The best response for the nurse is
- A. You can stop taking the Zoloft, but let's make another appointment with your provider so you can try a different medication.'
- B. Increased anxiety is a normal side effect for the first few weeks of taking this medication. It will take several weeks to determine if it is working. Please keep taking it as prescribed.'
- C. Increased anxiety is not a normal side effect of Zoloft. What day this week can you come to the clinic to discuss this with your provider?'
- D. Try taking half the prescribed dose for the next week and see if that helps the feelings of anxiety.'
Correct Answer: B
Rationale: Increased anxiety is a common early side effect of SSRIs like sertraline, which typically subsides after a few weeks. The therapeutic effect takes 4-6 weeks. Continuing the medication and monitoring is appropriate.
The home health nurse is visiting a client who plans to deliver her baby at home. Which statement by the client indicates an understanding regarding screening for phenylketonuria (PKU)?
- A. I will need to take the baby to the clinic within 24 hours of delivery to have blood drawn.
- B. I will need to schedule a home visit for PKU screening when the baby is 3 days old.
- C. I will remind the midwife to save a specimen of cord blood for the PKU test.
- D. I will have the PKU test done when I take her for her first immunizations.
Correct Answer: B
Rationale: PKU screening is typically performed at 2-3 days of age to ensure accurate results, as earlier testing may yield false negatives.
A client with a gastrointestinal bleed has an NG tube to low continuous wall suction. Which technique is the correct procedure for the nurse to utilize when assessing bowel sounds?
- A. Insert 10 mL of air in the NG tube and listen over the abdomen with a stethoscope
- B. Clamp the tube while listening to the abdomen with a stethoscope
- C. Irrigate the tube with 30 mL of NS while auscultating the abdomen
- D. Turn the suction on high and auscultate over the naval area
Correct Answer: B
Rationale: Clamping the NG tube prevents suction noise from interfering with auscultation, allowing accurate assessment of bowel sounds.