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 with DM is receiving care in the home for a foot ulcer. The home health nurse documents the narrative note illustrated. Which problem should be the nurse's priority on the return visit?
- A. Impaired skin integrity related to left foot ulcer
- B. Potential for injury related to improper footwear
- C. Potential altered nutrition: less than body requirements related to nausea
- D. Ineffective therapeutic regimen management related to not taking medications as prescribed
Correct Answer: B
Rationale: Improper footwear increases the risk of injury or falls, which is critical for a diabetic client with reduced foot sensation and a healing ulcer.
The nurse sustains a needle puncture that requires HIV prophylaxis. Which of the following medication regimens should be used?
- A. an antibiotic such as Metronidazole and a protease inhibitor (Saquinivir)
- B. two non-nucleoside reverse transcriptase inhibitors
- C. one protease inhibitor such as Nelfinavir
- D. two protease inhibitors
Correct Answer: B
Rationale: Unless there is drug resistance, the initial prophylaxis based on CDC recommendations is 2 NNRTIs.
A client continuously calls out to the nursing staff when anyone passes the client’s door and asks them to do something in the room. The best response by the charge nurse would be to
- A. keep the client’s room door cracked to minimize the distractions
- B. assign 1 of the nursing staff to visit the client regularly
- C. reassure the client that 1 staff person will check frequently if the client needs anything
- D. arrange for each staff member to go into the client’s room to check on needs every hour on the hour
Correct Answer: B
Rationale: Assign 1 of the nursing staff to visit the client regularly. Regular, frequent, planned contact by 1 staff member provides continuity of care and communicates to the client that care will be available when needed.
The hospitalized client tells the nurse about feeling a strong shock when turning on an electric hair dryer. What should the nurse do first?
- A. Assess the client's heart rhythm and apical pulse
- B. Disconnect the hair dryer from the electrical outlet
- C. Assess the client's skin for signs of electrical burn
- D. Tag and send the hair dryer for inspection
Correct Answer: A
Rationale: Assessing the client's heart rhythm is the priority, as an electrical shock can cause dysrhythmias due to the body's conductivity.
The nurse should perform which intervention when a client is restrained?
- A. Remove the restraints and provide skin care hourly.
- B. Document the condition of the client's skin every 3 hours.
- C. Assess the restraint every 30 minutes.
- D. Tie the restraint to the side rails.
Correct Answer: C
Rationale: The minimum standard is to visually assess the restraint every 30 minutes. Documentation is typically performed per a checklist or flow sheet. The ends of the restraint are tied to a part of the bed that allows for position changes without unfastening them.