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The nurse is reinforcing discharge instructions for several clients. Which client should receive information about the need for prophylactic antibiotics prior to dental procedures?
- A. Client who had mechanical aortic valve replacement
- B. Client who had mitral valvuloplasty repair
- C. Client who had myocardial infarction with subsequent heart failure
- D. Client who has mitral valve prolapse with regurgitation
Correct Answer: A
Rationale: Mechanical valve replacements (A) require prophylactic antibiotics before dental procedures to prevent endocarditis. Mitral valvuloplasty (B), heart failure (C), and mitral valve prolapse with regurgitation (D) have lower risks.
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An elderly client who experiences nighttime confusion wanders from his room into the room of another client. The nurse can best help decrease the client's confusion by:
- A. Assigning a nursing assistant to sit with him until he falls asleep
- B. Allowing the client to room with another elderly client
- C. Administering a bedtime sedative
- D. Leaving a night light on during the evening and night shifts
Correct Answer: D
Rationale: A night light reduces confusion by improving visibility and orientation. Constant supervision is impractical, room-sharing may worsen confusion, and sedatives increase fall risk.
The unlicensed assistive personnel (UAP) reports to the nurse that during rounds a client has recently become pale. What is the nurse's first action?
- A. Activate the facility's emergency response system
- B. Ask the UAP to obtain a full set of vital signs
- C. Check on the client to collect further data
- D. Immediately notify the health care provider
Correct Answer: C
Rationale: Assessing the client directly (C) confirms the report and guides next steps. Activating emergency response (A), delegating vitals (B), or notifying the provider (D) is premature without assessment.
The nurse is caring for a client with acute pancreatitis. While obtaining the client's blood pressure, the nurse notes a carpal spasm. The nurse should obtain a blood specimen to check the client's serum
- A. calcium level
- B. albumin level
- C. troponin T level
- D. potassium level
Correct Answer: A
Rationale: Carpal spasm (Trousseau's sign) suggests hypocalcemia (A), common in pancreatitis. Albumin (B), troponin (C), and potassium (D) are unrelated to this finding.
An adult client was admitted for congestive heart failure today. An IV is running. The nurse enters the room and notes that the client is having increased difficulty breathing. Before calling the physician, what action should the nurse take?
- A. Increase the IV drip rate
- B. Place the client in a supine position
- C. Ask the client if this has happened before
- D. Raise the head of the bed
Correct Answer: D
Rationale: Raising the head of the bed improves breathing in congestive heart failure by reducing pulmonary congestion. Increasing IV rate, supine positioning, or questioning delays intervention.
The student nurse verbalizes the procedure for obtaining a wound culture to the nurse preceptor. Which of the following statements by the student indicate a correct understanding?
- A. I will apply the prescribed bacitracin ointment after collecting the wound culture.
- B. I will cleanse the wound by gently flushing it with normal saline.
- C. I will obtain a sample of the drainage accumulated since the last dressing change.
- D. I will perform hand hygiene and apply new gloves before obtaining the wound culture.
- E. I will swab the wound from the outermost margin toward the center.
Correct Answer: B,D
Rationale: Cleansing the wound with normal saline (B) removes contaminants, and hand hygiene with gloves (D) ensures sterility. Applying ointment before the culture (A) could contaminate the sample. Swabbing from the outermost margin to the center (E) risks contaminating the sample with skin flora; the correct method is to swab the cleanest area first. Obtaining drainage since the last dressing change (C) may not target active infection.