Nokea
The nurse is talking with the parent of a 5-year-old client about managing recurrent nosebleeds at home. Which of the following statements would be appropriate for the nurse to make? Select all that apply.
- A. Apply direct pressure by pinching your child's nostrils together for 5-15 minutes.
- B. Take your child to the emergency department as soon as possible.
- C. Tell your child to lie down and turn your child on the left side.
- D. Provide reassurance to keep your child calm and quiet.
- E. Place a cold cloth over the bridge of your child's nose.
Correct Answer: A,D,E
Rationale: Pressure , reassurance , and cold cloth control bleeding and anxiety. ED visits are unnecessary for recurrent nosebleeds, and lying down risks aspiration.
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The nurse on the mental health unit is caring for assigned clients. The nurse should first check the client with
- A. obsessive-compulsive disorder who has spent the past hour counting socks
- B. major depressive disorder who has consumed no food from the past 2 meal trays
- C. posttraumatic stress disorder who reports a depressed mood and feelings of hopelessness
- D. bipolar I disorder who is experiencing an acute manic episode and reports sleeping 4 hours last night
Correct Answer: C
Rationale: Hopelessness and depressed mood in PTSD indicate suicide risk, requiring immediate assessment. OCD behavior , poor intake , and mania are less urgent but still need attention.
A client scheduled for a femoral popliteal bypass is to be assigned to a semi-private room. Which client would be the most suitable roommate for the client with a femoral popliteal bypass graft?
- A. A client with a pituitary tumor
- B. A client with respiratory sarcoidosis
- C. A client with a diabetic ulcer
- D. A client with a closed fracture of femur
Correct Answer: A
Rationale: The client with a pituitary tumor is the most suitable roommate as they are unlikely to have an infectious condition or mobility issues that could complicate recovery. Respiratory sarcoidosis may involve respiratory issues, increasing infection risk. A diabetic ulcer poses an infection risk due to potential open wounds. A closed femur fracture may involve similar mobility restrictions, complicating room logistics.
As the nurse observes the student nurse during the administration of a narcotic analgesic IM injection, the nurse notes that the student begins to give the medication without first aspirating. What should the nurse do?
- A. Ask the student: 'What did you forget to do?'
- B. Stop. Tell me why aspiration is needed.
- C. Loudly state: 'You forgot to aspirate.'
- D. Walk up and whisper in the student's ear 'Stop. Aspirate. Then inject.'
Correct Answer: D
Rationale: This action is a direct threat to the client if the medication enters into the blood stream instead of the muscle. The purpose of aspiration with IM injections is to prevent the injection of the drug directly into the blood stream.
Discharge medications
Aspirin: 81 mg by mouth, once daily
Clopidogrel: 75 mg by mouth, once daily
Rivaroxaban: 20 mg by mouth, once daily
Metoprolol: 25 mg by mouth, twice daily
Rosuvastatin: 20 mg by mouth, once daily
Lisinopril: 10 mg by mouth, once daily
A client with coronary artery disease and atrial fibrillation is being discharged home following coronary artery stent placement. Discharge medications are shown in the exhibit. The nurse identifies which educational topic as the highest priority to reinforce for this client?
- A. Bleeding risk
- B. Bronchospasm
- C. Muscle injury
- D. Tinnitus
Correct Answer: A
Rationale: Anticoagulants/antiplatelets for CAD/AF increase bleeding risk , the highest priority. Bronchospasm , muscle injury , and tinnitus are less relevant.
The nurse is caring for a client with acute pancreatitis. After pain management, which intervention should be included in the plan of care?
- A. Encourage the client to cough and deep breathe every 2 hours
- B. Place the client in contact isolation
- C. Provide a diet high in protein
- D. Institute seizure precautions
Correct Answer: A
Rationale: Encourage the client to cough and deep breathe every 2 hours. Coughing and deep breathing prevent respiratory infections due to shallow respirations.