Nokea
The nurse who is the primary caregiver for an adult client receives a telephone report from the Microbiology Department that the client's blood culture is positive for gram-negative rods. The client is not on antibiotics. What should the nurse do first?
- A. Document the result in the appropriate area of the chart
- B. Inform the client that the nurse now knows what is causing his illness
- C. Place a call to the physician and document the results of the lab work and the notification of the physician in the nurse's notes
- D. Place the laboratory report on the client's chart as soon as possible
Correct Answer: C
Rationale: Notifying the physician promptly ensures timely antibiotic initiation for a positive blood culture, the priority action.
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During the physical assessment, the nurse determines the need to perform the bulge Test .
Which of the following statements, if made by the nurse, is BEST?
- A. Please lie down and extend your legs.
- B. Please bend over and touch your toes.
- C. Please hold both hands behind your back.
- D. Please bend your elbow.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-bulge Test confirms presence of fluid in the knee; client's leg should be extended and supported on the bed (2) observing curve of spine; scoliosis will cause lateral curve in the spine (3) unrelated to knee examination (4) Test s articulation of elbow
The nurse is caring for a client with a history of Cushing’s syndrome.
- A. Which symptom is expected in a client with Cushing’s syndrome?
- B. Weight loss and fatigue.
- C. Moon face and truncal obesity.
- D. Hypotension and bradycardia.
- E. Polyuria and thirst.
Correct Answer: B
Rationale: Moon face and truncal obesity result from cortisol excess in Cushing’s syndrome. Weight loss, hypotension, and polyuria are more typical of Addison’s disease or diabetes insipidus.
Under the supervision of the registered nurse, a student nurse is changing the dressing of a 49-year-old woman with a newly inserted peritoneal dialysis catheter. Which of the following activities, if performed by the student nurse after removal of the old dressing, would require an intervention by the registered nurse?
- A. The student nurse cleans the catheter insertion site using a sterile cotton swab soaked in povidone-iodine.
- B. The student nurse applies two sterile precut 4 × 4s to the catheter insertion site.
- C. The student nurse cleans the insertion site using a circular motion from the outer abdomen toward the insertion site.
- D. The student nurse securely tapes the edges of the sterile dressing with paper tape.
Correct Answer: C
Rationale: should clean from insertion site outward toward outer abdomen
A 66-year-old woman is being evaluated for pernicious anemia. Which assessment findings would be most apt to be present in a client with pernicious anemia?
- A. Easy bruising
- B. Pain in the legs
- C. Fine red rash on the extremities
- D. Pruritus
Correct Answer: B
Rationale: Pernicious anemia, due to vitamin B12 deficiency, often causes neurological symptoms like leg pain or paresthesia. Bruising, rashes, or pruritus are less specific to this condition.
The nurse is caring for a client with a history of systemic lupus erythematosus.
- A. Which symptom is expected in a client with systemic lupus erythematosus?
- B. Chest pain and shortness of breath.
- C. Fever and joint pain.
- D. Weight gain and edema.
- E. Persistent headaches.
Correct Answer: B
Rationale: Fever and joint pain are common in systemic lupus erythematosus due to autoimmune inflammation. Chest pain may occur with pericarditis, but weight gain and headaches are less specific.