Nokea
The nurse receives the handoff of care report on four clients. Which client should the nurse see first?
- A. Client reporting incisional pain of 8 on a scale of 0-10 with a respiratory rate of 25/min who had a right pneumonectomy 12 hours ago
- B. Client with a left pleural effusion who has crackles, absent breath sounds in the left base, and an SpO2 of 94% on room air
- C. Client with a temperature of 100.4 F (38 C) and a respiratory rate of 12/min who had a small bowel resection 1 day ago
- D. Client with pneumonia who has a temperature of 97.6 F (36.4 C), has an SpO2 of 93% on 4 L/min supplemental oxygen, and is becoming restless
Correct Answer: D
Rationale: Restlessness in a pneumonia client with low SpO2 (D) suggests worsening hypoxia, requiring immediate assessment. Severe pain (A) is urgent but stable. Pleural effusion (B) and fever (C) are less critical.
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A client receiving end-of-life care is no longer able to make decisions. The client's appointed medical power of attorney (MPOA) is considering placement of a percutaneous enterogastric feeding tube. The MPOA asks the nurse, 'What would you do if this was your family member?' How should the nurse respond?
- A. I'm not sure what I would do, but I feel confident that you will make the right decision.
- B. I will call the chaplain to help you sort through the options and discuss the issue.
- C. What do you think are the advantages and disadvantages of a feeding tube?
- D. You should meet with the family to discuss what the patient would have wanted.
Correct Answer: C
Rationale: Exploring pros and cons (C) empowers the MPOA to make an informed decision. Personal opinions (A), chaplain referral (B), or family meetings (D) are less direct.
The nurse is teaching a client with dysrhythmia about the electrical pathway of an impulse as it travels through the heart. Which of these describes the normal pathway?
- A. AV node, SA node, Bundle of His, Purkinje fibers
- B. Purkinje fibers, SA node, AV node, Bundle of His
- C. Bundle of His, Purkinje fibers, SA node
- D. SA node, AV node, Bundle of His, Purkinje fibers
Correct Answer: D
Rationale: SA node, AV node, Bundle of His, Purkinje fibers. This is the normal pathway of an electrical impulse through the heart.
An 81-year-old client is admitted to a rehabilitation facility 3 days after total hip replacement. The next morning, the unlicensed assistive personnel (UAP) takes the client's vital signs, but when the UAP returns to assist the client with a shower, the client curses at and tries to hit the UAP. Which is the most appropriate response by the practical nurse?
- A. I will walk to the room to observe the client's behavior.
- B. It sounds like the client is not satisfied with the care provided. I'll see if we can make the client more comfortable.
- C. Just leave the client alone now and try again later.
- D. The client probably has dementia and is under a lot of stress with the change of environment.
Correct Answer: A
Rationale: Observing the client (A) allows assessment of the behavior's cause. Assuming dissatisfaction (B) or dementia (D) is premature. Leaving the client (C) delays intervention.
A woman is pregnant for the first time and is Rh negative. Her husband is Rh positive. She tells the nurse that he is very worried about her baby. Which information should the nurse plan to include when talking with this woman?
- A. The first baby should not be affected.
- B. She will need to get treatment after the second baby is born.
- C. There is nothing that can be done to prevent the baby from developing erythroblastosis fetalis, but it can be treated.
- D. She can have intrauterine transfusion for the first baby if blood levels indicate that the child is affected.
Correct Answer: A
Rationale: The first Rh-positive baby is typically unaffected as maternal antibodies develop post-delivery. RhoGAM is given after birth to prevent issues in future pregnancies, not after the second baby.
The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension. The nurse should:
- A. Question the order.
- B. Administer the medications.
- C. Administer them separately.
- D. Contact the pharmacy.
Correct Answer: B
Rationale: Lisinopril and furosemide are commonly prescribed together for hypertension, as lisinopril is an ACE inhibitor that reduces blood pressure, and furosemide is a diuretic that reduces fluid volume. There is no contraindication for administering them concomitantly, so answer A is incorrect. Administering them separately is unnecessary, so answer C is incorrect. Contacting the pharmacy is not needed unless there is a supply issue, so answer D is incorrect.