Nokea
For each assessment finding, click to specify if the finding is an indication of physical maltreatment, neglect, or financial maltreatment.
- A. Client reports having little food in the house.
- B. Client has bruises in various stages of healing.
- C. Client wears dirty clothing
- D. Client has no access to bank accounts
Correct Answer: A,B,C,D
Rationale: These findings suggest multiple forms of maltreatment.
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For each potential provider prescription click to specify if the prescription is anticipated or contraindicated for the client.
- A. Administer famotidine 20 mg via intermittent IV infusion twice daily.
- B. insert an indwelling urinary catheter.
- C. Administer lactated Ringer's 1L via IV bolus.
- D. Insert a nasogastric tube and maintain low intermittent suction.
Correct Answer: A,C,D
Rationale: [Explanation: The correct answer is - A,C,D. Administering famotidine helps reduce stomach acid, beneficial for clients with gastric issues. Lactated Ringer's IV bolus helps with fluid resuscitation. Inserting a nasogastric tube can help with decompression or feeding. Inserting an indwelling urinary catheter is not typically provider-initiated unless medically necessary. Therefore, A, C, and D are anticipated for client care, while B is contraindicated unless specifically indicated.]
A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?
- A. A client who has epidural analgesia and weakness in the lower extremities
- B. A client who has a hip fracture and a new onset of tachypnea
- C. A client who has sinus arrhythmia and is receiving cardiac monitoring
- D. A client who has diabetes mellitus and an HbA1c of 6.8%
Correct Answer: B
Rationale: The correct answer is B. The nurse should assess the client with a hip fracture and new onset of tachypnea first. Tachypnea in this client could indicate a potential complication such as a pulmonary embolism, which is a life-threatening condition requiring immediate intervention. Assessing this client first allows for prompt identification and management of any emergent issues. Clients with epidural analgesia and lower extremity weakness (choice A) may indicate a neurological concern but are not as urgent as tachypnea in a client with a hip fracture. Sinus arrhythmia with cardiac monitoring (choice C) and diabetes mellitus with an HbA1c of 6.8% (choice D) do not present immediate life-threatening situations that require immediate assessment compared to the client with a hip fracture and tachypnea.
Which of the following examples should the nurse include in the teaching as an example of malpractice?
- A. Documenting communication with a provider in the progress notes of the client's medical record
- B. Placing a yellow bracelet on a client who is at risk for falls
- C. Leaving a nasogastric tube clamped after administering oral medication
- D. Administering potassium via IV bolus
Correct Answer: C
Rationale: The correct answer is C because leaving a nasogastric tube clamped after administering oral medication is an example of malpractice. This action can lead to obstruction and potential harm to the client. Documenting communication (A) is a standard practice to ensure accurate record-keeping. Placing a yellow bracelet (B) is a safety measure. Administering potassium via IV bolus (D) is within the scope of practice if done correctly.
A nurse is caring for a client who is immobile. Which of the following interventions is appropriate to prevent contracture?
- A. Position a pillow under the client's knees.
- B. Place a towel roll under the client's neck.
- C. Align a trochanter wedge between the client's legs
- D. Apply, an orthotic to the client's foot
Correct Answer: D
Rationale: The correct answer is D: Apply an orthotic to the client's foot. This intervention helps to maintain proper alignment of the foot, preventing contractures that can occur due to prolonged immobility. Placing a pillow under the client's knees (choice A) is beneficial for reducing pressure on the lower back but does not specifically address foot contractures. Similarly, placing a towel roll under the client's neck (choice B) is helpful for neck support but does not prevent foot contractures. Aligning a trochanter wedge between the client's legs (choice C) is aimed at hip alignment and not foot contractures. Therefore, the most appropriate intervention to prevent foot contractures in an immobile client is applying an orthotic to the client's foot.
Which of the following anterior chest wall locations should the nurse auscultate?(You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
Correct Answer:
Rationale: Correct Answer: D (Second intercostal space, right sternal border)
Rationale: The nurse should auscultate at the second intercostal space, right sternal border to listen to the aortic valve. This location corresponds to the area where the aortic valve can be best heard. The aortic valve is located in the second intercostal space, right sternal border, so auscultating at this spot allows for accurate assessment of the heart sounds in this area. It is essential to auscultate at this specific location to detect any abnormalities or abnormalities in the aortic valve.
Summary of other choices:
- A, B, C, E, F, G: These locations do not correspond to the specific area where the aortic valve is best heard. Auscultating at these locations may not provide clear or accurate heart sounds related to the aortic valve.