Nokea
The nurse is talking with a client whose spouse recently died. The client states, 'I just cannot get over my spouse's death.' Which of the following responses would be appropriate for the nurse to make?
- A. A friend of mine recently died. I know how hard losses can be.
- B. It may take a while, but coming to terms with loss will get easier with time.
- C. I see that you are upset. I will give you some time alone so you can process these feelings.
- D. Have you considered attending a support group to help you process grief?
- E. This is a difficult time. Tell me about how you have been coping.
Correct Answer: B,D,E
Rationale: The nurse should provide empathetic, open-ended responses that encourage the client to express feelings and explore coping strategies. Suggesting a support group (D) and asking about coping methods (E) are therapeutic. Acknowledging that grief takes time (B) is supportive. Sharing personal experiences (A) is unprofessional, and leaving the client alone (C) may dismiss their emotional needs.
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The nurse has been made aware of laboratory test results for a client who is receiving continuous cardiac monitoring. The client is asymptomatic, and the cardiac monitor shows normal sinus rhythm. Which of the following is most likely an erroneous test result?
- A. BUN of 60 mg/dL (21.4 mmol/L)
- B. serum sodium level of 155 mEq/L (155 mmol/L)
- C. serum potassium level of 7.0 mEq/L (7.0 mmol/L)
- D. serum creatinine level of 4.0 mg/dL (353.6 μmol/L)
Correct Answer: C
Rationale: A potassium level of 7.0 mEq/L (C) is life-threatening and would likely cause arrhythmias, inconsistent with normal sinus rhythm and asymptomatic status, suggesting an error. Elevated BUN (A), sodium (B), and creatinine (D) are concerning but plausible in renal or dehydration issues without immediate cardiac effects.
A client is admitted for hemodialysis. Which abnormal lab value would the nurse anticipate not being improved by hemodialysis?
- A. Low hemoglobin
- B. Hypernatremia
- C. High serum creatinine
- D. Hyperkalemia
Correct Answer: A
Rationale: Low hemoglobin. Hemodialysis corrects electrolyte imbalances but does not improve anemia.
During change-of-shift report, the nurse going off duty notes that the nurse coming on has an alcohol smell on the breath and slurred speech. What actions are most important for the nurse to take?
- A. Do not continue the handoff report with the oncoming nurse
- B. Document the incident according to facility policy
- C. Notify the charge nurse
- D. Say nothing but watch for impaired behavior
- E. Tell the oncoming nurse that he/she is not fit for duty
Correct Answer: B,C
Rationale: Notifying the charge nurse (C) and documenting (B) ensure patient safety and follow protocol. Stopping handoff (A) disrupts care continuity. Watching silently (D) delays action, and confronting directly (E) may escalate the situation.
The nurse in the pediatric clinic is planning to reinforce postoperative teaching to parents. The nurse should talk with the parent of which child first?
- A. 2-year-old with bilateral tympanostomy tubes who has a small piece of plastic in the right outer ear
- B. 4-year-old post adenotonsillectomy who is now reporting ear pain
- C. 6-year-old with strep throat who needs a note to return to school 24 hours after starting antibiotics
- D. 7-year-old 5 days post tonsillectomy who wants to return to soccer practice tomorrow
Correct Answer: A
Rationale: A foreign object in the ear (A) poses an immediate risk of injury or infection, requiring urgent attention. Ear pain post-adenotonsillectomy (B) is common and less urgent. School clearance (C) and returning to sports (D) are non-emergent.
There has been a large-scale community disaster and clients must be roomed together at the hospital. Who are appropriate roommates in light of infection risk principles?
- A. A client diagnosed with varicella and a client with pertussis
- B. A client placed in an airborne infection isolation room (AIIR) and a client with heart failure
- C. A client receiving chemotherapy and a client with chronic obstructive pulmonary disease (COPD) coughing yellow sputum
- D. A client with pelvic inflammatory disease (PID) and a client with coffee ground emesis
- E. Two clients diagnosed with tuberculosis
Correct Answer: D
Rationale: PID and coffee ground emesis (D) are non-infectious, making them suitable roommates. Varicella, pertussis, TB (A, E), and COPD with sputum (C) pose infection risks. AIIR (B) is for airborne infections, incompatible with heart failure.