Nokea
The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. Which action should the nurse take?
- A. Select another finger.
- B. Assess radial pulse volume.
- C. Collect the blood sample.
- D. Apply pressure to the site.
Correct Answer: D
Rationale: Applying pressure reduces engorgement, ensuring an accurate glucose sample and preventing trauma.
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A client with stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a 0 to 10 scale. Which intervention should the nurse implement?
- A. Educate client on signs and symptoms of narcotic dependency.
- B. Administer opioid and non-opioid medication simultaneously.
- C. Give maximum dosage when score reaches 10.
- D. Alternate IV and IM analgesic medications.
Correct Answer: B
Rationale: Combining opioid and non-opioid medications provides synergistic pain relief, optimizing control while minimizing opioid side effects.
The nurse is caring for a client after a coronary artery bypass graft surgery. The client is exhibiting pitting edema of the lower extremities and jugular venous distention with increased central venous pressure. Which condition should the nurse suspect the client is experiencing based on these findings?
- A. Right-sided heart failure.
- B. Left ventricular dysfunction.
- C. Cardiac tamponade.
- D. Internal bleeding.
Correct Answer: A
Rationale: Right-sided heart failure causes systemic venous congestion, leading to edema, jugular distention, and elevated central venous pressure.
The nurse is preparing a client for surgery who was admitted from the emergency department following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site. During the preoperative assessment, the nurse determines that the client currently receives heparin sodium 5,000 units SUBQ daily. Which nursing action is a priority?
- A. Notify the healthcare provider of the client's medication history.
- B. Have the client sign the surgical and transfusion permits.
- C. Observe the heparin injections sites for signs of bruising.
- D. Ensure that the potential for bleeding is explained to the client.
Correct Answer: A
Rationale: Notifying the provider about heparin use is critical to manage perioperative bleeding risk due to its anticoagulant effects.
A client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client?
- A. Bradycardia and constipation.
- B. Lethargy and lack of appetite.
- C. Muscle cramping and dry, flushed skin.
- D. Palpitations and shortness of breath.
Correct Answer: D
Rationale: Palpitations and shortness of breath indicate hyperthyroidism from excessive levothyroxine, requiring dosage adjustment.
The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?
- A. Do your family members share combs and brushes?
- B. Do you have any dry patches on your feet and hands?
- C. Has everyone at home already had varicella?
- D. Have the antifungal creams been effective?
Correct Answer: C
Rationale: Asking about varicella history assesses the risk of chickenpox transmission to susceptible household members from herpes zoster.