Nokea
The nurse is preparing to assist a client to ambulate to the bathroom. The client rises from the chair at the bedside and immediately reports feeling dizzy. It would be a priority for the nurse to
- A. Check the client's orthostatic blood pressure
- B. encourage the client to remain on bed rest
- C. apply a gait belt around the client's waist
- D. assist the client back to a sitting position
Correct Answer: D
Rationale: Dizziness upon standing suggests orthostatic hypotension or other instability. Assisting the client back to a sitting position prevents falls and ensures immediate safety.
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What should be included in the care plan of a client who has myxedema?
- A. Encourage frequent rest periods
- B. Have the client do deep breathing and coughing exercises frequently
- C. Provide a cool environment
- D. Offer frequent high-calorie snacks
Correct Answer: A
Rationale: Myxedema (severe hypothyroidism) causes fatigue; frequent rest periods conserve energy. Deep breathing, cool environments, or high-calorie snacks are not prioritized.
The nurse has assigned a nursing assistant to give the client a bath. Which observation reported by the nursing assistant requires immediate attention by the nurse?
- A. A red area on the back that disappears after it is massaged
- B. A red area on the hip that does not go away after the area is massaged
- C. The client's insistence on doing most of the bath
- D. The indwelling urethral catheter is draining clear, amber urine.
Correct Answer: B
Rationale: A non-blanching red area on the hip suggests a pressure injury, requiring immediate nursing intervention to prevent progression.
A 20-year-old woman is admitted to the hospital following an accident. Her uncle, a physician from out of state, visits her and asks to see her chart. How should the nurse respond?
- A. Comply with the request and give the chart to the physician
- B. Explain that written permission from his niece is needed first
- C. Suggest that he discuss the case with the attending physician
- D. Give him the chart but do not let him remove it from the nurse's station
Correct Answer: B
Rationale: HIPAA regulations require patient consent for chart access, even by a physician relative, unless they are directly involved in care. Permission from the patient is needed first.
Four clients were involved in a major highway motor vehicle accident. Which client requires priority care?
- A. Client with blood pressure of 90/70 mm Hg and deviated trachea
- B. Client with concussion who was unconscious for 5 minutes
- C. Client with grossly swollen upper thigh and blood pressure of 80/60 mm Hg
- D. Client with pain at the thoracic spine and complete paralysis of both legs
Correct Answer: A
Rationale: A deviated trachea and hypotension suggest tension pneumothorax, a life-threatening condition requiring immediate decompression to restore breathing.
The nurse is reviewing prescriptions for assigned adult clients. The nurse should question the prescription for
- A. 0.45% sodium chloride for a client with syndrome of inappropriate antidiuretic hormone secretion who has a decreased sodium level
- B. 0.9% sodium chloride for a client with gastrointestinal bleeding who has a decreased hemoglobin level
- C. 1,000 mL bolus of 0.9% sodium chloride for a client with septic shock who has an increased WBC count
- D. lactated Ringer solution for a client with hypovolemic shock and a thermal burn who has an increased hematocrit level
Correct Answer: A
Rationale: 0.45% sodium chloride is hypotonic and can worsen hyponatremia in SIADH by further diluting serum sodium, requiring clarification for a hypertonic solution.