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The nursing assistant reports to the nurse that a client who is one-day postoperative after an angioplasty is refusing to eat and states, 'I just don't feel good.' Which of the following actions, if taken by the nurse, is BEST?
- A. The nurse talks with the client about how he is feeling.
- B. The nurse instructs the nursing assistant to sit with the client while he eats.
- C. The nurse contacts the physician to obtain an order for an antacid.
- D. The nurse evaluates the most recent vital signs recorded in the chart.
Correct Answer: A
Rationale: assessment required; monitor for closure of vessel, bleeding, hypotension, dysrhythmias
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The charge nurse on a surgical unit incorporates an authoritative style of leadership. Which characteristics describe this style of leadership? Select all that apply.
- A. involves little planning
- B. motivates staff by coercion
- C. motivates staff by supporting their achievements
- D. involves communication flow down the chain of command
- E. includes group members in the decision-making process
Correct Answer: B, D
Rationale: Authoritative leadership involves top-down communication and can use coercion to motivate, focusing on control rather than collaboration or support.
Which of the following is a characteristic of an ominous periodic change in the fetal heart rate?
- A. A fetal heart rate of 120-130 bpm
- B. A baseline variability of 6-10 bpm
- C. Accelerations in FHR with fetal movement
- D. A recurrent rate of 90-100 bpm at the end of the contractions.
Correct Answer: D
Rationale: A recurrent fetal heart rate of 90-100 bpm at contraction ends indicates severe distress, an ominous sign.
A client is being discharged with an implantable cardioverter-defibrillator (ICD), and the nurse is educating the client about home management. The client asks what he should do if the ICD fires one time but he has no other symptoms. Which of the following is the best advice?
- A. Call 9-1-1.
- B. Go to the emergency department when recovered from the firing.
- C. Resume normal activities.
- D. Lie down and rest and report the event to the physician by telephone.
Correct Answer: D
Rationale: A single ICD firing without symptoms should be reported to the physician (D) for evaluation. Calling 9-1-1 (A) or going to the ED (B) is unnecessary, and resuming activities (C) may be premature.
The nurse who is caring for a client with cancer notes a WBC of 500 on the laboratory results. Which intervention would be most appropriate to include in the client's plan of care?
- A. Assess temperature every 4 hours because of risk for hypothermia
- B. Instruct the client to avoid large crowds and people who are sick
- C. Instruct in the use of a soft toothbrush
- D. Assess for hematuria
Correct Answer: B
Rationale: A WBC of 500 indicates severe neutropenia, increasing infection risk. Avoiding crowds and sick people is critical to prevent infections. The other interventions are less specific.
The nurse is performing discharge teaching to the parents of a 7-year-old who has been diagnosed with asthma. Which sports activity would be most appropriate for this client?
- A. Baseball
- B. Swimming
- C. Football
- D. Track
Correct Answer: B
Rationale: Swimming is ideal for asthma clients as it promotes controlled breathing in a warm, humid environment, reducing the risk of exercise-induced bronchospasm.