Nokea
The nurse reinforces teaching about methotrexate to a client with rheumatoid arthritis. It is most important to address which topic regarding this drug?
- A. Need for an eye examination
- B. Need for sunblock
- C. Risk for infection
- D. Risk for kidney injury
Correct Answer: C
Rationale: Methotrexate suppresses the immune system, significantly increasing the risk for infection (C). This is a critical teaching point to ensure the client takes precautions. Eye exams (A), sunblock (B), and kidney injury (D) are less directly associated with methotrexate's primary risks.
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The nurse is assisting with care of a client with blunt head injury admitted for observation, including hourly neurologic checks. At 1:00 AM, the client reports a headache; the neurologic check is normal, and the nurse administers acetaminophen prn. At 2:00 AM, the client appears to be sleeping. What action does the nurse anticipate taking?
- A. Arouse the client and ask what the current month is
- B. Awaken the client and check for paresthesia
- C. Document 'relief apparently obtained' and recheck at 3:00 AM
- D. Let the client sleep but verify respiratory rate
Correct Answer: A
Rationale: Hourly neurologic checks require arousing the client to assess orientation (A). Checking paresthesia (B), assuming relief (C), or only verifying respiratory rate (D) do not meet monitoring requirements.
Diagnosis-related groups (DRGs) provide data to
- A. Identify clients who have specific medical diagnoses
- B. Identify findings related to a medical diagnosis
- C. Determine reimbursement for a medical diagnosis
- D. Implement nursing care based on case management protocol
Correct Answer: C
Rationale: Determine reimbursement for a medical diagnosis. DRGs are the basis of prospective payment plans for reimbursement for Medicare clients.
Vital signs
Temperature 95 F (35 C)
Blood pressure 90/50 mm Hg
Heart rate 50/min
Respirations 6/min
SpO2 83%
The nurse is caring for a client with hypothyroidism who has become lethargic and difficult to rouse. Which action is the priority?
- A. Administer scheduled PO levothyroxine
- B. Perform bag-valve-mask ventilation
- C. Place a warming blanket on the client
- D. Review client's thyroid laboratory results
Correct Answer: B
Rationale: Lethargy and unresponsiveness in hypothyroidism suggest myxedema coma, requiring immediate airway management with ventilation (B). Levothyroxine (A), warming (C), and lab review (D) are secondary.
A 70 year-old post-operative client has elevated serum BUN, HCT, Cl, and Na+. Creatinine and K+ are within normal limits. The nurse should perform additional assessments to confirm that an actual problem is:
- A. Impaired gas exchange
- B. Metabolic acidosis
- C. Renal insufficiency
- D. Fluid volume deficit
Correct Answer: D
Rationale: Fluid volume deficit. In fluid volume deficit, serum BUN, Na+, and hematocrit may be elevated secondary to hemoconcentration.
The home health aide reports to the practical nurse that the client has been trying to give away possessions. When the nurse asks the client about this behavior, the client says, 'With my spouse dead, there's no reason for me to go on.' What is the best response by the nurse?
- A. Are you having any thoughts of hurting yourself?'
- B. Do you have any friends in the building?'
- C. Tell me more about how you're feeling.'
- D. You're not thinking of killing yourself, are you?'
Correct Answer: A
Rationale: The client's statement and behavior suggest suicidal ideation. Directly asking about thoughts of self-harm (A) is the most appropriate response to assess risk and ensure safety. Options B, C, and D are less direct and may delay critical intervention.