Nokea
The nurse receives report on the group of clients listed here. Place the client list in sequential priority order for the nurse to assess. (Most important for the nurse to assess first, second, third, and fourth.)
- A. Client admitted from the emergency room previous shift with unrelieved migraine headache.
- B. Client transferred from surgical intensive care after traumatic brain injury. Pulse oximetry reading 94%.
- C. Client with a Glasgow coma scale (GCS) of 5 with evidence of cerebral aneurysm rupture on CT scan.
- D. Client admitted from the emergency room after a motor vehicle accident and GCS of 13
Correct Answer: C, B, D, A
Rationale: Priority: GCS 5 with aneurysm (C) is life-threatening, followed by traumatic brain injury (B, potential deterioration), motor vehicle accident with GCS 13 (D, stable but needs monitoring), and migraine (A, non-emergent).
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The nurse is caring for a client with a history of atrial fibrillation. Which medication is most likely to be prescribed to prevent thromboembolism?
- A. Warfarin (Coumadin)
- B. Aspirin
- C. Clopidogrel (Plavix)
- D. Heparin
Correct Answer: A
Rationale: Warfarin is commonly prescribed for atrial fibrillation to prevent thromboembolism by maintaining anticoagulation (target INR 2–3). Aspirin and clopidogrel are less effective, and heparin is used short-term.
A client has a tentative diagnosis of myasthenia gravis. The nurse recognizes that myasthenia gravis involves:
- A. Loss of the myelin sheath in portions of the brain and spinal cord
- B. An interruption in the transmission of impulses from nerve endings to muscles
- C. Progressive weakness and loss of sensation that begins in the lower extremities
- D. Loss of coordination and stiff 'cogwheel' rigidity
Correct Answer: B
Rationale: Myasthenia gravis is caused by autoantibodies blocking acetylcholine receptors, interrupting nerve impulse transmission to muscles, leading to weakness.
Before administering eardrops to a toddler,the nurse should recognize that it is essential to consider which of the following?
- A. Age
- B. Weight
- C. Developmental level
- D. Ability to understand
Correct Answer: C
Rationale: The toddler’s developmental level affects cooperation and ability to follow instructions during eardrop administration. Age is a factor but less specific and weight or understanding are secondary to developmental considerations.
On morning rounds, the nurse found a manic-depressive client who is taking lithium in a confused mental state, vomiting, twitching, and exhibiting a coarse hand tremor. Which one of the following nursing actions is essential at this time?
- A. Administer her next dosage of lithium, and then call the physician.
- B. Withhold her lithium, and report her symptoms to the physician.
- C. Place her on NPO to decrease the excretion of lithium from her body, and call the physician.
- D. Contact the lab and request a lithium level in 30 minutes, and call the physician.
Correct Answer: B
Rationale: The client has lithium toxicity, and the nurse must withhold further dosages. Because of her level of toxicity, further lithium could cause coma and death. The nurse needs further orders from the physician to stabilize the client's lithium level.
A client had a hemicolectomy performed 2 days ago. Today, when the nurse assesses the incision, a small part of the abdominal viscera is seen protruding through the incision. This complication of wound healing is known as:
- A. Excoriation
- B. Dehiscence
- C. Decortication
- D. Evisceration
Correct Answer: D
Rationale: Evisceration occurs when the incision separates and the contents of the cavity spill out.