Nokea
The nurse is planning care for all of the following clients. Which client should be cared for first?
- A. A 60-year-old who is three days postop and needs a dressing change and ambulation
- B. A 75-year-old who had a suprapubic prostatectomy yesterday and says, 'Take that tube out of me, I have to pee.'
- C. A 90-year-old who had a total hip replacement two days ago and is to get out of bed today
- D. A 50-year-old who had an abdominal cholecystectomy yesterday and is asking for pain medication
Correct Answer: B
Rationale: The 75-year-old post-prostatectomy client's request to remove the catheter and urgency to urinate suggest potential catheter obstruction or bladder irritation, which could lead to complications like infection or bladder damage. This requires immediate assessment and intervention, taking priority over routine dressing changes, scheduled mobility, or pain management.
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All of the following individuals live at home with their families. Which of the following persons is least at risk for abuse?
- A. An 82-year-old woman who is incontinent and bosses people around
- B. An 80-year-old man who is ambulatory with help following a brain attack
- C. A 78-year-old woman who asks for help with all of her activities of daily living
- D. A 75-year-old man who wanders at night and frequently yells out
Correct Answer: B
Rationale: The ambulatory man with minimal dependency is least likely to be abused, as he retains some independence. Incontinence, high dependency, or disruptive behavior increase vulnerability.
The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the following actions by the nurse would be appropriate?
- A. Schedule the therapy thirty minutes after meals
- B. Teach the child not to cough during the treatment
- C. Continue the percussion to the rib cage area
- D. Place the child in a prone position for the therapy
Correct Answer: C
Rationale: Continue the percussion to the rib cage area. Percussion should target the rib cage to mobilize secretions effectively.
The nurse is caring for four antepartum clients. Which client should the nurse see first?
- A. Client with hyperemesis gravidarum who is currently vomiting (9%)
- B. Client with molar pregnancy who has dark brown vaginal discharge (8%)
- C. Client with suspected ectopic pregnancy who has abdominal and shoulder pain (71%)
- D. Client with threatened miscarriage who says, 'I am a Jehovah's Witness.' (10%)
Correct Answer: C
Rationale: A suspected ectopic pregnancy is a medical emergency due to the risk of rupture and internal bleeding, which can be life-threatening. Abdominal and shoulder pain are hallmark symptoms, indicating possible referred pain from diaphragmatic irritation. This client requires immediate assessment and intervention, prioritizing over hyperemesis gravidarum (which, while serious, is less immediately life-threatening), molar pregnancy (which needs monitoring but is not an acute emergency), and threatened miscarriage (which requires evaluation but is less urgent without active bleeding or pain).
A client arrives at the clinic for a follow-up after an emergency department visit the night before. The client sustained an ulnar fracture, and a fiberglass cast was applied. Which of the following teachings related to cast care should the nurse reinforce? Select all that apply.
- A. Contact the clinic if any hot areas or foul odors develop in the cast
- B. Cover the cast with a plastic bag for bathing, and avoid getting the cast wet
- C. Elevate the affected extremity above heart level for the first 48 hours
- D. Expect some numbness and tingling of the fingers during the first week
- E. Use only soft, padded objects to scratch the skin under the cast
Correct Answer: A,B,C,E
Rationale: Hot areas or odors (A) suggest infection, keeping the cast dry (B) prevents skin breakdown, elevation (C) reduces swelling, and soft objects (E) avoid injury. Numbness and tingling (D) are not normal and may indicate nerve compression, requiring immediate reporting.
Which medication prescriptions should the nurse question? Select all that apply.
- A. Cephalexin for a client with severe allergy to penicillin
- B. Fexofenadine for a client with hives
- C. Ibuprofen for a client with asthma and nasal polyps
- D. Lisinopril for a client with diabetes mellitus
- E. Propranolol for a client with asthma
Correct Answer: A,C,E
Rationale: Cephalexin (A) is contraindicated in penicillin allergy due to cross-reactivity risk. Ibuprofen (C) can trigger bronchospasm in aspirin-exacerbated respiratory disease, common in asthma with nasal polyps. Propranolol (E) is contraindicated in asthma due to beta-blockade causing bronchoconstriction. Fexofenadine (B) is safe for hives, and lisinopril (D) is appropriate for diabetes to protect kidneys.