Nokea
The nurse is performing a physical examination of a 3 month-old with a suspected heart murmur. Which assessment should be performed first?
- A. Inspect the chest
- B. Auscultate the mass
- C. Percuss the mass
- D. Palpate the mass
Correct Answer: B
Rationale: Auscultate the mass. Auscultation of the chest to listen for a heart murmur is the first step in confirming the presence of a murmur and guides further assessment.
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The client that the nurse is ambulating becomes dizzy and feels faint. Place the nurse's actions in the correct order to prevent the client from falling.
- A. Support and ease the client to the floor by sliding the client down the forward leg
- B. Call for help
- C. Bend at the knees and pull the client toward the forward leg
- D. Assess the client for injuries
- E. Protect the client's head from hitting objects on the floor
- F. Assume a broad stance with the stronger leg somewhat behind the other leg
Correct Answer: B,F,C,A,E,D
Rationale: The sequence ensures safety: call for help (B), establish a stable stance (F), lower the client safely (C, A), protect the head (E), and assess injuries (D).
After working with a client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had it with that demanding client. I just can't do anything that pleases him. I'm not going in there again." The nurse should respond by saying
- A. He has a lot of problems. You need to have patience with him.
- B. I will talk with him and try to figure out what to do.
- C. He may be scared and taking it out on you. Let's talk to figure out what to do.
- D. Ignore him and get the rest of your work done. Someone else can take care of him for the rest of the day.
Correct Answer: C
Rationale: This response explains the client's behavior without belittling the UAP's feelings. The UAP is encouraged to contribute to the plan of care to help solve the problem.
The nurse is caring for a client who has just returned from the operating room after a cholecystectomy. Which of these findings requires immediate follow-up by the nurse?
- A. A temperature of 100.4°F (38°C)
- B. Pulse rate of 110 beats per minute
- C. Respiratory rate of 24 breaths per minute
- D. Oxygen saturation of 88%
Correct Answer: D
Rationale: An oxygen saturation of 88% indicates hypoxia, requiring immediate intervention to prevent respiratory compromise.
A client has been placed in isolation because he is diagnosed with a contagious illness. The nurse should be aware that:
- A. Linens from the client's bed should be double-bagged.
- B. Meals should be served on washable dishes.
- C. Extensive isolation rarely causes psychological problems.
- D. Paper trays and plastic utensils prevent disease transmission.
Correct Answer: A
Rationale: Linens should be double-bagged. Isolation refers to techniques used to prevent or to limit the spread of infection. Some form of isolation has been used for centuries, whether to protect a high-risk person from exposure to pathogens or to prevent the transmission of pathogens from an infected person to others. Special handling of articles and linen soiled by any body fluid is indicated. These articles should be placed in impervious bags before they are removed from the client's bedside. Bagging in watertight containers is indicated to prevent exposure of personnel and contamination of the environment. The outside of the bag should not be contaminated when placing articles inside it. Each hospital and community agency has procedures for labeling and decontaminating exposed articles. Items that are visibly soiled with body substances should be rinsed and placed in plastic bags or clearly marked containers, often labeled 'Contaminated.' If the outside of the bag becomes contaminated, placing that bag in another bag (double-bagging) is required.
When a drug is listed as Category X and prescribed to women of child-bearing age/capacity, the nurse and the interdisciplinary team should counsel the client that:
- A. Pregnancy tests might be unreliable while taking the drug.
- B. She must use a reliable form of birth control.
- C. She should not take the Category X drug on days she has intercourse.
- D. She must follow up with an endocrinologist.
Correct Answer: B
Rationale: Category X drugs have many practice limitations when prescribed and dispensed to women. For example, the prescription is valid for only seven days, and if not filled, it expires. The FDA provides a pregnancy-prevention program for clients taking Isotretinoin (Accutane). Prior to prescribing a Category X drug, a pregnancy test should be performed.