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The nurse is making patient assignments on a medical/surgical unit. The staff includes one RN, one RN pulled from the pediatric floor, an LPN/LVN, and a nursing assistant. Which of the following patients should be assigned to the RN from the pediatric floor?
- A. A client one-day postoperative after an appendectomy.
- B. A client who had a detached retina surgically repaired 4 hours ago.
- C. A client with a Sengstaken-Blakemore tube in place.
- D. A client two-days postoperative after a laminectomy with spinal fusion.
Correct Answer: A
Rationale: stable patient with expected outcome
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An 8-year-old boy is brought to the physician’s office by his mother. The mother is concerned because the boy has a fever, vomited twice, and slept all day yesterday with the curtains closed. The boy complains of headache, nausea, and has a temperature of 103°F (39.3°C). The nurse observes the boy has a petechial rash on the trunk of his body. Which of the following assessments would be MOST important for the nurse to perform?
- A. Grasp the child’s hands and ask him to squeeze the nurse’s hands.
- B. Stroke the plantar surface of the child’s foot with a reflex hammer.
- C. Gently flex the child’s head and neck onto the chest.
- D. Have the child stand with his eyes closed, his arms at his sides, and his feet and knees close together.
Correct Answer: C
Rationale: Fever, headache, nausea, and petechial rash suggest meningitis; flexing the neck (Brudzinski’s sign) assesses meningeal irritation, a priority. Options A, B, and D are less relevant: hand squeeze is nonspecific, Babinski’s sign is not indicated, and Romberg’s sign assesses balance.
The nurse is caring for a client with a history of gastroesophageal reflux disease (GERD).
- A. Which instruction is most appropriate for a client with GERD?
- B. Eat large meals to reduce acid production.
- C. Lie down immediately after eating.
- D. Elevate the head of the bed during sleep.
- E. Avoid drinking water with meals.
Correct Answer: C
Rationale: Elevating the head of the bed during sleep prevents acid reflux by using gravity to keep stomach contents down. Large meals and lying down post-meal worsen reflux, and water is neutral.
The nurse is caring for clients in the pediatric clinic.
- A. Which finding in a six-month-old infant requires follow-up?
- B. The anterior fontanel is open.
- C. The child is not sitting unsupported.
- D. The child is not pulling to a standing position.
- E. The child is not rolling from abdomen to back.
Correct Answer: C
Rationale: By six months, infants typically pull to a standing position with support. Failure to do so may indicate developmental delay, requiring follow-up. An open anterior fontanel is normal until 18 months, sitting unsupported begins around 7-8 months, and rolling over is expected by 5-6 months.
The nurse is caring for a 22-year-old woman who is completing the first stage of labor. The woman's husband is at her side and has been coaching her according to exercises they learned at natural childbirth classes. Suddenly the woman begins to shake and screams, 'I can't stand this anymore!' The nurse should encourage the husband to
- A. instruct his wife to use shallow respirations during the contractions.
- B. offer his wife ice chips or sips of water to distract her from the pain.
- C. stroke his wife's abdomen between contractions.
- D. review with his wife the breathing pattern needed at each stage of labor.
Correct Answer: A
Rationale: entering transition phase of first stage of labor, slow shallow breaths needed (pant breathing)
The nursing staff is planning to use behavior modification techniques for an elderly woman who constantly screams. Which of the following nursing assessments is necessary to establish a successful program?
- A. Monitor the client's ability to complete her activities of daily living (ADL).
- B. Assess the client's levels of pain and correlate it with her response to analgesia.
- C. Observe the client's behavior at regular intervals to obtain baseline information related to her screaming.
- D. Ask the client why she is screaming and document it on her nursing assessment record.
Correct Answer: C
Rationale: to design an effective behavior modification program, accurate baseline data must first be collected about the target behavior in relation to frequency, amount, time, and precipitating factors