Nokea
The nurse notes that the client has a pulse deficit. What is the most appropriate action for the nurse?
- A. Document this as a normal finding.
- B. Instruct the client to report to the clinic for a weekly reevaluation.
- C. Report this finding immediately to the client's physician.
- D. Teach the client how to monitor pulse at home.
Correct Answer: C
Rationale: A pulse deficit indicates irregular heartbeats, requiring immediate physician notification to assess for arrhythmias.
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The nurse is caring for a client with a deep vein thrombosis. Which finding would require the nurse's immediate attention?
- A. Temperature of 102 degrees Fahrenheit
- B. Pulse rate of 98 beats per minute
- C. Respiratory rate of 32
- D. Blood pressure of 90/50
Correct Answer: C
Rationale: Respiratory rate of 32. Clients with deep vein thrombosis are at risk for the development of pulmonary embolism (PE). The most common symptoms of PE are tachypnea, dyspnea, and chest pain.
A 3-year-old child who is up to date with all immunizations is seen at clinic. The child has a fever of 102°F and a pruritic rash with fluid-filled vesicles that began on the trunk. The physician says the child has varicella. The child's mother says to the nurse, 'I thought my child couldn't get this because she had all her shots.' What is the best response for the nurse to make?
- A. You child probably did not respond to the vaccine as most children do.
- B. The nurse must not have administered it correctly.
- C. It is still possible to contract the illness, but your child will most likely have a less severe case.
- D. The vaccine is only effective after the child has received two doses.
Correct Answer: C
Rationale: The varicella vaccine reduces severity but does not guarantee immunity; breakthrough cases are milder, as indicated by the child's symptoms.
In providing care to a 14 year-old adolescent with scoliosis, which of the following will be most difficult for this client?
- A. Compliance with treatment regimens
- B. Looking different from their peers
- C. Lacking independence in activities
- D. Reliance on family for their social support
Correct Answer: B
Rationale: Looking different from their peers. Conformity is critical at age 14, and visible differences due to scoliosis treatment can be challenging.
A home care nurse is planning activities for the day. Which of the following clients should the nurse see FIRST?
- A. A new mother is breastfeeding her two-day-old infant who was born five days early.
- B. A man discharged yesterday following treatment with IV heparin for a deep vein thrombosis.
- C. An elderly woman discharged from the hospital three days ago with pneumonia.
- D. An elderly man who used all his diuretic medication and is expectorating pink-tinged mucus.
Correct Answer: D
Rationale: symptoms of pulmonary edema; requires immediate attention
The nurse is caring for a 1 year-old child who has 6 teeth. What is the best way for the nurse to give mouth care to this child?
- A. Using a moist soft brush or cloth to clean teeth and gums
- B. Swabbing teeth and gums with flavored mouthwash
- C. Offering a bottle of water for the child to drink
- D. Brushing with toothpaste and flossing each tooth
Correct Answer: A
Rationale: Using a moist soft brush or cloth to clean teeth and gums. The nurse should use a soft cloth or soft brush to do mouth care so that the child can adjust to the routine of cleaning the mouth and teeth.