Nokea
The nurse should visit which of the following clients first?
- A. The client with diabetes with a blood glucose of $95 \mathrm{mg} / \mathrm{dL}$
- B. The client with hypertension being maintained on Lisinopril
- C. The client with chest pain and a history of angina
- D. The client with Raynaud's disease
Correct Answer: C
Rationale: Chest pain in a client with a history of angina suggests possible acute coronary syndrome, requiring immediate assessment to rule out myocardial infarction.
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The nurse is caring for a client with a history of HIV/AIDS.
- A. Which laboratory finding is most concerning for a client with HIV/AIDS?
- B. CD4 count of 150 cells/mm³.
- C. Viral load of 10,000 copies/mL.
- D. White blood cell count of 5,000/mm³.
- E. Hemoglobin of 12.0 g/dL.
Correct Answer: A
Rationale: A CD4 count of 150 cells/mm³ indicates severe immunosuppression in HIV/AIDS, increasing infection risk and requiring immediate intervention. High viral load is concerning but less urgent, and normal WBC and hemoglobin are unremarkable.
The nurse responds to a train derailment.
After making an initial assessment, which of the following clients should the nurse see FIRST?
- A. A pregnant woman who states that her clothing is wet.
- B. A young man with blood pulsating from a cut on the right leg.
- C. A preschool child who is screaming and crying uncontrollably.
- D. An unconscious woman with the right leg shorter than the left leg.
Correct Answer: B
Rationale: Strategy: Think ABCs. (1) requires further assessment, could be amniotic fluid or it could be urine (2) correct-indicates arterial bleeding; apply direct pressure; high risk for shock (3) stable patient (4) possible hip fracture, no indication of respiratory difficulty stated
The nurse is caring for a client with a history of heart failure who is receiving digoxin (Lanoxin) 0.25 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I feel tired in the afternoon.
- B. I have nausea and no appetite.
- C. I have a headache sometimes.
- D. I take my medication with food.
Correct Answer: B
Rationale: Nausea and loss of appetite are signs of digoxin toxicity, a serious complication requiring immediate evaluation, especially in heart failure. Options A, C, and D are less concerning: fatigue and headaches are nonspecific, and taking digoxin with food is acceptable.
During administration of oral medications to an elderly, confused client, the client states, 'These pills look funny. They belong to the lady down the hall.' Which of the following is the BEST response by the nurse?
- A. Your physician has ordered new medications for you. They will help you get well.
- B. Remember yesterday when I brought your medications? They look the same.
- C. I'll explain why you are receiving these medications.
- D. I'll be back after I check your medications again.
Correct Answer: D
Rationale: Rechecking medications ensures safety, addressing the client’s concern about a possible error. Options A, B, and C risk administering incorrect drugs.
The nurse is performing a physical assessment on a client with insulin dependent diabetes mellitus. Which client finding calls for immediate nursing action?
- A. Diaphoresis and shakiness
- B. Reduced lower leg sensation
- C. Intense thirst and hunger
- D. Painful hematoma on thigh
Correct Answer: A
Rationale: Diaphoresis and shakiness. Diaphoresis is a sign of hypoglycemia, which warrants immediate attention to prevent severe complications.