Nokea
The nurse observes a patient walking to the bathroom with a stooped gait, facial grimacing, and gasping sounds. Which of the following should the nurse assess in the patient?
- A. Pain
- B. Anxiety
- C. Depression
- D. Fluid volume deficit
Correct Answer: A
Rationale: Stooped gait, grimacing, and gasping suggest pain, requiring immediate assessment. Anxiety, depression, or fluid deficit are less likely based on these signs.
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Your client is reluctant to take a necessary dose of narcotic analgesic for severe pain. The client states, 'I do not want to become a druggie.' How would you respond to this client's comment?
- A. That is ridiculous. Nobody gets addicted to narcotics when they do not have a prior history of drug abuse.
- B. The possible complications of unrelieved pain greatly outweigh the risk of addiction which is very low when a person has no prior history of drug abuse.
- C. A lot of people prefer to be brave and stick it out so you are not alone.
- D. You have a right to refuse any and all treatments, so just do without it.
Correct Answer: B
Rationale: Addressing pain complications and reassuring low addiction risk educates and encourages treatment. Dismissing concerns, normalizing endurance, or supporting refusal are non-therapeutic.
The nurse is participating in a committee changing the hospital security plan. Which of the following statements by the nurse would be appropriate to make? Select all that apply.
- A. Open visitation should be implemented in the newborn nursery.
- B. Visitors should always wear a badge while in the hospital
- C. Oral temperatures should be obtained for all visitors
- D. Hand sanitizing stations should be offered throughout the facility
- E. Disaster drills should be conducted to ensure staff competency
Correct Answer: B,D,E
Rationale: Visitor badges, hand sanitizing stations, and disaster drills enhance security. Open visitation in nurseries and visitor temperature checks are impractical or unsafe.
The nurse is educating the parents of a child who plans on riding their bicycle. Which statements, if made by the parents, indicate effective understanding?
- A. I should tell my child to ride their bike against the traffic pattern.
- B. I should instruct my child to walk their bike through busy intersection crosswalks.
- C. Wearing a helmet is only necessary when my child is riding near a busy intersection.
- D. My child can ride their bike barefoot as long as it's short distances.
Correct Answer: B
Rationale: Walking the bike through busy intersections enhances safety. Riding against traffic, optional helmet use, and barefoot riding are unsafe.
The following scenario applies to the next 1 items
The nurse cares for a client on the oncology floor
Item 1 of 1
Admission Note
Physician Orders
The client was admitted for observation after reporting increasing fatigue, dyspnea, malaise, and a fever of 102°F (38.8°C). The client is currently being treated with doxorubicin for uterine sarcoma. The initial diagnostic testing revealed pneumonia and neutropenia.
The nurse recognizes that this client is at increased risk for developing ………………… therefore, the nurse should implement neutropenic precautions which involves …………………. Considering the client has a fever, the nurse anticipates an order for ……………
- A. systemic infection
- B. chronic renal failure
- C. washing hands frequently.
- D. wearing sterile gloves for client care.
- E. performing frequent oral care.
- F. 24-hour urine collection.
- G. collecting blood cultures.
Correct Answer: A,C,G
Rationale: Neutropenia increases systemic infection risk, requiring frequent handwashing and blood cultures for fever evaluation.
The perioperative nurse is documenting a client's current health status. It would be correct for the nurse to document the client's current position as: See the image in the exhibit.
- A. Prone
- B. Supine
- C. Trendelenburg position
- D. The Sims’ position
Correct Answer: C
Rationale: This picture shows the Trendelenburg position. The body is laid supine or flat on the back on a 15-30 degree incline with the feet elevated above the head. The Trendelenburg position increases the venous blood return to the heart when a client is affected by hypotension, hypovolemia, or shock. This position also improves spinal anesthesia's effects and prevents air embolism during central venous cannulation