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The nurse is reviewing the vital signs of a client admitted with atrial fibrillation. The client's vital signs are: T 37.5°C (99.6°F), P 88 and irregular, RR 20, BP 90/56 mmHg, pulse oximetry reading 96% on room air. The nurse should immediately address which vital sign?
- A. Temperature
- B. Blood pressure
- C. Respiratory rate
- D. Pulse
Correct Answer: B
Rationale: Low BP (90/56 mmHg) indicates potential hemodynamic instability, requiring immediate attention in atrial fibrillation. Temperature, respiratory rate, and pulse are less critical.
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The nurse is teaching a client about a vegan diet. Which of the following foods should the nurse recommend for this diet? Select all that apply.
- A. Legumes
- B. Tofu
- C. Almonds
- D. Prunes
- E. Baked fish
- F. Grapefruit
Correct Answer: A,B,C,D,F
Rationale: Vegan diets exclude animal products, so legumes, tofu, almonds, prunes, and grapefruit are suitable. Baked fish is not vegan.
The nurse is counseling a client diagnosed with irritable bowel syndrome (IBS). The nurse should advise the client to increase their
- A. Dairy intake.
- B. Fiber intake.
- C. Fat intake.
- D. Calcium intake.
Correct Answer: B
Rationale: Fiber regulates bowel function in IBS. Dairy and fat may worsen symptoms, and calcium is unrelated to IBS management.
The nurse is participating in a committee reviewing strategies to reduce falls in older adults. Which of the following recommendations by the nurse would be appropriate to make?
- A. Increase the availability of bedside commodes
- B. Recommend the occupational therapist assess the client for mobility and safety
- C. Reduce environmental lighting, especially at night
- D. Remove grab bars from the bathrooms
Correct Answer: A,B
Rationale: Bedside commodes and occupational therapy assessments reduce fall risk by improving access and mobility. Reducing lighting and removing grab bars increase fall risk.
The home health nurse is caring for a 67-year-old female client with progressive multiple sclerosis.
Item 3 of 6
Current Medications
Nurses' Notes
• cephalexin 500 mg p.o. every six hours for 10 days
• diazepam 5 mg p.o. daily PRN muscle spasm
• multivitamin 1 tablet daily
• ergocalciferol 10,000 international units p.o. Daily
The nurse updates the nursing note with an environmental assessment for a 67-year-old female client with progressive multiple sclerosis. The nurse should first address the client's
- A. fatigue.
- B. sensation in the extremities.
- C. nutritional intake.
- D. environmental hazards.
Correct Answer: D
Rationale: Environmental hazards (e.g., furniture used for ambulation) pose an immediate fall risk, which is critical to address first for safety.
The nurse is caring for a client two days post-operative following gastroduodenostomy. After reviewing the clinical data, the nurse should take which action?
- A. obtain a prescription for an antihypertensive
- B. determine if the client's pain is being controlled
- C. assess the client's surgical wound for signs of infection
- D. notify the physician for concerns of hypovolemic shock
Correct Answer: D
Rationale: Without specific clinical data, the priority for a client two days post-gastroduodenostomy is to assess for hypovolemic shock, a potential complication due to bleeding or fluid loss from the surgical site. This is more urgent than pain control, wound infection assessment, or antihypertensive needs, which require specific clinical indicators.