Nokea
The nurse sees a client walking in the hallway who begins to have a seizure. The nurse should do which of the following in priority order?
- A. Maintain a patent airway.
- B. Record the seizure activity observed.
- C. Ease the client to the floor.
- D. Obtain vital signs.
Correct Answer: C,A,B,D
Rationale: The priority order is: 1) Ease the client to the floor to prevent injury (C); 2) Maintain a patent airway to ensure oxygenation (A); 3) Record seizure activity for accurate reporting (B); 4) Obtain vital signs post-seizure to assess stability (D).
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Of the clients listed below, who is at risk for developing rheumatoid arthritis (RA)? Select all that apply.
- A. Adults between the ages of 20 and 50 years.
- B. Adults who have had an infectious disease with the Epstein-Barr virus.
- C. Adults that are of the male gender.
- D. Adults who possess the genetic link, specifically HLA-DR4.
- E. Adults who also have osteoarthritis.
Correct Answer: A,B,D
Rationale: Rheumatoid arthritis is more common in adults aged 20-50, has a genetic association with HLA-DR4, and may be linked to Epstein-Barr virus. Males are less likely than females to develop RA, and osteoarthritis is a distinct condition.
The nurse is conducting a postoperative assessment of a client on the first day after renal surgery. Which of the following findings would be most important for the nurse to report to the physician?
- A. Temperature, 99.8°F (37.7°C).
- B. Urine output, 20 mL/hour.
- C. Absence of bowel sounds.
- D. A 2€ x 2€ area of serosanguineous drainage on the flank dressing.
Correct Answer: B
Rationale: Urine output of 20 mL/hour is critically low, indicating potential renal compromise or obstruction, requiring immediate physician notification.
The nurse is planning care for a client on complete bed rest. The plan of care should include all except which of the following:
- A. Turning every 2 hours
- B. Passive and active range-of-motion exercises
- C. Use of thromboembolic disease support (TED) hose
- D. Maintaining the client in the supine position
Correct Answer: D
Rationale: Maintaining the client in the supine position is not recommended, as it promotes stasis and pressure ulcers. Turning every 2 hours, range-of-motion exercises, and TED hose prevent complications like thrombophlebitis and skin breakdown during bed rest.
In the oliguric phase of acute renal failure, the nurse should assess the client for:
- A. Pulmonary edema.
- B. Metabolic alkalosis.
- C. Hypotension.
- D. Hypokalemia.
Correct Answer: A
Rationale: Pulmonary edema is a risk in the oliguric phase due to fluid overload from reduced urine output.
The nurse should assess a client with thrombocytopenia who has developed a hemorrhage for which of the following?
- A. Tachycardia.
- B. Bradycardia.
- C. Decreased urine output.
- D. Hypotension.
Correct Answer: A
Rationale: Hemorrhage in a client with thrombocytopenia can lead to hypovolemia, causing tachycardia as the heart compensates for decreased blood volume. Bradycardia is not typical, and while decreased urine output and hypotension may occur later, tachycardia is an earlier and more immediate sign.