Nokea
The nurse receives a report on an older adult client with middle stage dementia. What information suggests the nurse should do immediate follow up rather than delegate care to the nursing assistant? The client
- A. has had a change in respiratory rate by an increase of 2 breaths
- B. has had a change in heart rate by an increase of 10 beats
- C. was minimally responsive to voice and touch
- D. has had a blood pressure change by a drop in 8 mmHg systolic
Correct Answer: C
Rationale: A change in level of consciousness indicates delirium related to acute illness. This would require the assessment of a nurse. The other changes could occur within the range of normal fluctuations.
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The nurse is teaching the client with a latex allergy about home and personal safety. Which information should the nurse emphasize? Select all that apply.
- A. Remove items in the home made from synthetic materials.
- B. Keep emergency telephone numbers readily accessible.
- C. Have someone remove any latex balloons and rubber bands.
- D. Avoid foods such as kiwi, bananas, avocados, and chestnuts.
- E. Certain plants, such as poinsettia plants, help remove allergens.
Correct Answer: B,C,D
Rationale: B: Emergency numbers are critical for anaphylaxis. C: Latex items like balloons and rubber bands must be removed to avoid exposure. D: Certain foods can trigger cross-reactive allergic reactions. A and E are incorrect as synthetic materials are safe, and poinsettias can cause reactions.
The client with a left-sided weakness is to be discharged to home, where the client has an electrical bed. In preparation for discharge, the nurse assesses the client's ability to get out of bed independently- Which client actions indicate that further instruction is needed? Select all that apply.
- A. Places the bed in the lowest position
- B. Raises the head of the bed (HOB)
- C. Rolls onto the left side
- D. Pushes against the mattress with the weak elbow and stronger hand to rise to a sitting position
- E. Slides legs off the bed while pushing against the mattress to raise the body off the bed
- F. Once in a sitting position, sits at the edge of the bed for a few minutes before standing
Correct Answer: C,D
Rationale: C: Rolling onto the weaker left side is incorrect; the client should roll onto the stronger right side to maximize strength and stability. D: Using the weak elbow instead of the stronger elbow and hand to push off increases the risk of injury and instability.
The nurse confides to a coworker that when reporting a change in the client's condition to the HCP, the HCP stated, "It seems that every time you work, there is some catastrophe. Can't you problem-solve earlier so this doesn't happen!" What is the coworker's best response?
- A. "This HCP responds to everyone the same. You did everything right; don't feel bad."
- B. "You should obtain our hospital policy and initiate the steps to report the HCP."
- C. "Let the nurse manager know; I think our manager is already dealing with the HCP."
- D. "Let's go to the medical director, who should be told about this HCP's angry response."
Correct Answer: B
Rationale: Reporting the HCP's uncivil behavior per hospital policy is the best response to address and document the issue appropriately.
A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia (MRSA). What type of isolation is most appropriate for this client?
- A. Reverse
- B. Airborne
- C. Standard precautions
- D. Contact
Correct Answer: D
Rationale: Contact precautions or Body Substance Isolation (BSI) involves the use of barrier protection (e.g. gloves, mask, gown, or protective eyewear as appropriate) whenever direct contact with any body fluid is expected.
The nurse suspects that a child may have ingested a caustic substance. Which comment by the child would be of greatest concern to the nurse?
- A. Ask the child if the mouth is burning or throat pain is present.'
- B. I feel sleepy and my stomach hurts.'
- C. My tongue feels funny and I’m thirsty.'
- D. Has the child had vomiting, diarrhea or stomach cramps?'
Correct Answer: A
Rationale: Local irritation of tissues indicates a corrosive poisoning. Burning in the mouth or throat pain suggests ingestion of a caustic substance, requiring immediate attention.