Nokea
The nurse recognizes that it is acceptable for which pair of clients to be assigned to share a semi-private room?
- A. 35-year-old with blood loss anemia and a 28-year-old diagnosed with severe anorexia nervosa
- B. 50-year-old who had a bowel resection 2 days ago and a 40-year-old diagnosed with pneumonia
- C. 60-year-old who had a total hip arthroplasty yesterday and a 58-year-old with fever of unknown origin
- D. 60-year-old with gastroenteritis and a 70-year-old with diarrhea and vomiting related to chemotherapy
Correct Answer: D
Rationale: Clients with gastroenteritis and chemotherapy-induced diarrhea (D) have similar non-airborne conditions, making them suitable roommates. Pneumonia (B) and fever of unknown origin (C) pose infection risks. Anemia and anorexia (A) are unrelated but not optimal.
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During change-of-shift report, the nurse going off duty notes that the nurse coming on has an alcohol smell on the breath and slurred speech. What actions are most important for the nurse to take?
- A. Do not continue the handoff report with the oncoming nurse
- B. Document the incident according to facility policy
- C. Notify the charge nurse
- D. Say nothing but watch for impaired behavior
- E. Tell the oncoming nurse that he/she is not fit for duty
Correct Answer: B,C
Rationale: Notifying the charge nurse (C) and documenting (B) ensure patient safety and follow protocol. Stopping handoff (A) disrupts care continuity. Watching silently (D) delays action, and confronting directly (E) may escalate the situation.
While performing an initial assessment on a newborn following a breech delivery, the nurse suspects hip dislocation. Which of the following is most suggestive of the abnormality?
- A. Flexion of lower extremities
- B. Negative Ortolani response
- C. Lengthened leg of affected side
- D. Irregular hip symmetry
Correct Answer: D
Rationale: Irregular hip symmetry. Early assessment of irregular hip symmetry alerts the nurse and the provider to a correctable congenital hip dislocation.
A nurse on an orthopedic unit is caring for four clients with a casted extremity. Which client does the nurse prioritize to see first?
- A. Client reporting a tingling sensation
- B. Client reporting itching under the cast
- C. Client reporting pain of 5/10 on movement
- D. Client reporting throbbing on dependent positioning
Correct Answer: A
Rationale: Tingling (A) suggests neurovascular compromise, requiring urgent assessment. Itching (B), moderate pain (C), and throbbing (D) are less critical.
The mother of a newborn asks why the nurse is checking the baby's nose. The nurse replies that it is important to check nasal patency because the newborn:
- A. does not have the ability to sneeze.
- B. must breathe through his nose.
- C. is subject to periods of apnea.
- D. has rapid respirations.
Correct Answer: B
Rationale: Newborns are obligate nose breathers, making nasal patency critical to prevent respiratory distress. Sneezing ability, apnea, or rapid respirations are unrelated.
The nurse is caring for a client with benign prostatic hypertrophy (BPH). Which of the following assessments would the nurse anticipate finding?
- A. Large volume of urinary output with each voiding
- B. Involuntary voiding with coughing and sneezing
- C. Frequent urination
- D. Urine is dark and concentrated
Correct Answer: C
Rationale: Frequent urination. BPH causes overflow incontinence with frequent urination in small amounts due to bladder obstruction.