Nokea
The nurse notes all of the following. Which should be attended to first?
- A. A blind client is calling out stating that she cannot find the call bell.
- B. There is a water spill on the floor near the bed of an elderly client who ambulates regularly.
- C. A postoperative client is asking for pain medication.
- D. A diabetic client is asking for a glass of water.
Correct Answer: B
Rationale: A water spill near an ambulatory elderly client's bed poses an immediate fall risk, requiring prompt attention to ensure safety. Call bell access, pain, or water requests are less critical.
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Which statement by the parent of a child with sickle cell anemia indicates an understanding of the disease.
- A. The pain he has is due to the presence of too many red blood cells.'
- B. He will be able to go snow skiing with his friends as long as he stays warm.'
- C. He will need extra fluids in the summer to prevent dehydration.'
- D. There is very little chance that his brother will have sickle cell.'
Correct Answer: C
Rationale: Extra fluids in summer prevent dehydration, which can trigger sickle cell crises. Pain is due to vaso-occlusion, not excess RBCs; skiing risks hypoxia; siblings have a 25% chance of inheriting the disease.
The nurse responds to the call light of a client with chronic obstructive pulmonary disease (COPD) who says, 'I can't breathe.' The client seems to be having difficulty breathing and is nervous and tremulous. Vital signs are stable, oxygen saturation is 92% on 2 L, and there are clear breath sounds bilaterally. Which intervention would be most appropriate at this time?
- A. Administer albuterol nebulizer
- B. Assist the client in identifying the trigger and ways to avoid it
- C. Coach the client through controlled breathing exercises
- D. Continue to monitor oxygen saturation
Correct Answer: C
Rationale: For a COPD client with anxiety-driven dyspnea, stable vitals, and clear lungs, coaching controlled breathing helps reduce anxiety and improve breathing patterns. Albuterol is for bronchospasm, trigger identification is secondary, and monitoring is insufficient alone.
A client who has congestive heart failure is being admitted. How should the nurse position this client?
- A. Supine
- B. Sims'
- C. Semi-sitting
- D. Side-lying
Correct Answer: C
Rationale: Semi-sitting (Fowler's position) reduces cardiac workload and improves breathing in congestive heart failure by decreasing venous return.
The nurse in the emergency department is caring for a client who sustained blunt force head trauma and is experiencing blurry vision. The nurse should suspect the client has sustained injury to the
- A. temporal lobe
- B. occipital lobe
- C. parietal lobe
- D. frontal lobe
Correct Answer: B
Rationale: Blurry vision post-head trauma suggests injury to the occipital lobe , which processes visual information. Temporal , parietal , and frontal lobes manage other functions.
Which client event would be considered an adverse event and would require completion of an incident/event/irregular occurrence/variance report? Select all that apply.
- A. Administered 9.00 AM medication at 9.30 AM
- B. Developed worsening cellulitis after missing antibiotics for 1 day
- C. Has a seizure and a history of epilepsy
- D. Slides off the edge of the bed and ends up sitting on the floor
- E. Waits 4 hours to be transported for STAT diagnostic CT scan
Correct Answer: B,D,E
Rationale: Adverse events requiring an incident report include worsening cellulitis due to missed antibiotics , a fall even without injury , and a significant delay in a STAT procedure . Late medication administration is a variance but not typically an adverse event unless harm occurs, and a seizure in a known epileptic is expected unless protocol was not followed.