Nokea
The nurse is talking with a 74-year-old client with previously well-controlled hypertension. The client currently has a blood pressure of 190/88 mm Hg and has had a cold with nasal congestion for the past 3 days. Which of the following questions would be most important for the nurse to ask?
- A. Have you received the influenza vaccine recently?
- B. Are you taking over-the-counter cold medications?
- C. Have you spent time with your grandchildren recently?
- D. Are you taking over-the-counter vitamin C supplements?
Correct Answer: B
Rationale: OTC cold medications (e.g., decongestants) can elevate blood pressure, explaining the sudden increase, making this the most important question.
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The emergency department nurse is caring for a 70-year-old client with a history of type 2 diabetes mellitus who reports sudden-onset nausea, sweating, dizziness, and fatigue. The nurse should anticipate the initiation of which protocol?
- A. Food poisoning
- B. Influenza
- C. Myocardial infarction
- D. Stroke
Correct Answer: C
Rationale: Symptoms like nausea, sweating, dizziness, and fatigue in a 70-year-old with diabetes suggest myocardial infarction, requiring immediate cardiac protocol initiation.
The nurses on a unit are planning for stoma care for clients who have a stoma for fecal diversion. Which stomal diversion poses the highest risk for skin breakdown?
- A. Ileostomy
- B. Transverse colostomy
- C. Ileal conduit
- D. Sigmoid colostomy
Correct Answer: A
Rationale: Ileostomy output contains caustic gastric and enzymatic agents that can denude skin quickly.
The nurse is observing a client who sustained a left ankle sprain ascending the stairs using a modified 3-point gait. The nurse should intervene if the client is observed
- A. bearing weight on the right leg
- B. realigning the crutches between each step
- C. assuming the tripod position before ascending the stairs
- D. using the right crutch to support the weight while advancing the left leg onto the next step
Correct Answer: D
Rationale: In a modified 3-point gait, the injured leg (left) should not bear weight, and the right crutch with the left leg should not be used alone to advance. The other actions are consistent with proper crutch use.
The nurse has reinforced teaching with the parents of a 6-year-old client with chronic allergic rhinitis that is triggered by dust and pollen. Which of the following statements by the parents would indicate a correct understanding of the teaching? Select all that apply.
- A. We are planning to purchase an air purifier with a high-efficiency particulate air filter
- B. We will keep the windows open during warm weather to air out our house.
- C. We should place hypoallergenic covers on our child's mattress and pillow.
- D. We will clean our wood floors with a damp mop at least once a week
- E. We are planning to remove the carpet from our child's bedroom.
Correct Answer: A,C,D,E
Rationale: Correct choices reduce allergen exposure: HEPA filters remove dust/pollen, hypoallergenic covers prevent dust mite exposure, damp mopping reduces dust, and removing carpets eliminates allergen reservoirs. Keeping windows open increases pollen exposure, worsening symptoms.
The nurse is preparing to perform wound irrigation for a client who sustained a scalp laceration. Which of the following actions should the nurse take?
- A. Hold the syringe 8 in (20.3 cm) above the wound.
- B. Use a 10 mL syringe to draw up the irrigation solution.
- C. Position the client so the irrigation solution flows from the most to least contaminated area.
- D. Flush the wound with low, continuous pressure and dry the surrounding area with sterile gauze.
Correct Answer: C
Rationale: Irrigation should flow from the least to most contaminated area to prevent infection spread. Other options are incorrect techniques.