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The nurse's assignment consists of the following four clients. From highest to lowest priority, in which order should the nurse assess the clients after receiving morning report?
- A. The client with cirrhosis who became confused and disoriented during the night.
- B. The client with acute pancreatitis who is requesting pain medication.
- C. The client who is 1 day postoperative following a cholecystectomy and has a T-tube inserted.
- D. The client with hepatitis B who has questions about his discharge instructions.
Correct Answer: A,B,C,D
Rationale: Confusion in cirrhosis (A) indicates possible hepatic encephalopathy, a priority. Pain in pancreatitis (B) requires prompt relief. Postoperative T-tube monitoring (C) is next. Discharge teaching (D) is lowest priority.
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A client with renal calculi has hematuria. The nurse should:
- A. Monitor urine output.
- B. Notify the physician immediately.
- C. Restrict fluids.
- D. Apply ice to the flank.
Correct Answer: A
Rationale: Hematuria is expected with renal calculi; monitoring ensures no excessive bleeding.
A nurse is assessing a client with bone cancer pain. Which of the following components of a thorough pain assessment is most significant for this client?
- A. Intensity.
- B. Cause.
- C. Aggravating factors.
- D. Location.
Correct Answer: A
Rationale: Pain intensity is the most significant component in assessing bone cancer pain, as it guides the urgency and type of pain management interventions needed.
The client tells the nurse that he is allergic to shellfish. The nurse should ask the client if he is also allergic to:
- A. All other seafood.
- B. Iodine skin preparations.
- C. Caffeine.
- D. Alcohol-based skin preparations.
Correct Answer: B
Rationale: Shellfish allergies are often associated with iodine sensitivity, as shellfish contain iodine. Iodine-based skin preparations used in surgery could trigger an allergic reaction, so this must be assessed. Other options are unrelated to shellfish allergies.
The nurse is planning a home visit for a client with hepatitis. In order to prevent transmission the nurse should focus teaching on:
- A. Proper food handling.
- B. Insulin syringe disposal.
- C. Alpha-interferon.
- D. Use of condoms.
Correct Answer: D
Rationale: Hepatitis B and C are transmitted via body fluids, so condom use (D) prevents sexual transmission. Food handling (A) is more relevant for hepatitis A. Syringe disposal (B) applies to needle-sharing risks, and alpha-interferon (C) is treatment, not prevention.
When a client is diagnosed with aplastic anemia, the nurse should assess the client for changes in which of the following physiologic functions?
- A. Bleeding tendencies.
- B. Intake and output.
- C. Peripheral sensation.
- D. Bowel function.
Correct Answer: A
Rationale: Aplastic anemia causes pancytopenia, including thrombocytopenia, which increases the risk of bleeding. The nurse should assess for bleeding tendencies, such as petechiae, bruising, or mucosal bleeding. Intake/output, sensation, and bowel function are not primarily affected.