Nokea
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 because a client with a hip fracture and new onset of tachypnea may have a pulmonary embolism, a life-threatening complication that requires immediate assessment and intervention. Tachypnea can indicate hypoxia, which can be fatal if not addressed promptly. The nurse should prioritize assessing this client to ensure timely management and prevent further deterioration.
Clients A, C, and D do not present with immediate life-threatening conditions that require urgent assessment compared to client B. Client A's weakness in the lower extremities, client C's sinus arrhythmia, and client D's HbA1C level do not pose immediate risks to their health. Therefore, the nurse should assess client B first to address the potential pulmonary embolism.
You may also like to solve these questions
A nurse is planning teaching for a client and their family about home oxygen therapy. Which of the following information should the nurse plan to include in the teaching?
- A. Apply petroleum jelly to soothe the mucous membranes.
- B. Use synthetic fabrics for the client's bedding.
- C. Clean the equipment with an alcohol-based cleaning product.
- D. Avoid using nail polish remover around the client.
Correct Answer: D
Rationale: The correct answer is D: Avoid using nail polish remover around the client. Nail polish remover contains acetone, which is highly flammable and can pose a serious risk when in contact with oxygen therapy equipment. It is crucial to prevent any potential sources of ignition near oxygen therapy to ensure the safety of the client.
Incorrect choices:
A: Apply petroleum jelly to soothe the mucous membranes - Petroleum jelly is flammable and should not be used near oxygen therapy.
B: Use synthetic fabrics for the client's bedding - The type of bedding material is not directly related to home oxygen therapy.
C: Clean the equipment with an alcohol-based cleaning product - Alcohol-based products are flammable and should be avoided around oxygen therapy equipment.
A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take?
- A. Document the client's behavior prior to being placed in seclusion.
- B. Assess the client's behavior once every hour.
- C. Offer fluids every 2 hours.
- D. Discuss with the client his inappropriate behavior prior to seclusion.
Correct Answer: A
Rationale: The correct answer is A because documenting the client's behavior before seclusion is essential for comprehensive care, ensuring accurate assessment, and treatment planning. This documentation provides crucial information for evaluating the effectiveness of seclusion, understanding triggers, and creating a safer environment. Assessing the client's behavior, offering fluids, or discussing inappropriate behavior are important but secondary to documenting behavior for legal, ethical, and continuity of care reasons. Monitoring behavior continuously is more effective than hourly assessments.
A nurse is reinforcing teaching with a client who has hypertension and a prescription to measure her blood pressure daily. Which of the following client statements indicates an understanding of the teaching?
- A. I will wait 15 minutes after drinking coffee to measure my blood pressure.
- B. I will measure my blood pressure while my arm is elevated above my heart.
- C. I should remove constrictive clothing prior to measuring my blood pressure.
- D. I should measure my blood pressure immediately after eating breakfast.
Correct Answer: C
Rationale: The correct answer is C: "I should remove constrictive clothing prior to measuring my blood pressure." Removing constrictive clothing ensures accurate blood pressure measurement by allowing the cuff to fit properly on the arm without any restrictions, leading to a more reliable reading. Choice A is incorrect as coffee can temporarily increase blood pressure. Choice B is incorrect because the arm should be at heart level, not elevated. Choice D is incorrect as blood pressure should be measured on an empty stomach for accuracy.
A nurse is conducting health promotion education regarding contraindications to combination oral contraceptive use to a group of women. Which of the following conditions should the nurse include in the teaching?
- A. Hypertension
- B. Fibromyalgia
- C. Renal calculi
- D. Fibrocystic breast disease.
Correct Answer: A
Rationale: The correct answer is A: Hypertension. Hypertension is a contraindication to combination oral contraceptive use due to the increased risk of cardiovascular events. The estrogen component in oral contraceptives can further elevate blood pressure, leading to complications. Other choices like B: Fibromyalgia, C: Renal calculi, and D: Fibrocystic breast disease are not contraindications for oral contraceptive use. Fibromyalgia is a chronic pain condition unrelated to oral contraceptives. Renal calculi are kidney stones, which do not directly affect the safety of oral contraceptives. Fibrocystic breast disease is a benign condition and not a contraindication to oral contraceptives.
A nurse is performing postmortem care for a recently deceased client prior to the client's family viewing. Which of the following actions should the nurse take?
- A. Cross the client's arms across their chest.
- B. Hold the client's eyes shut for a few seconds.
- C. Place the client in a high-Fowler's position.
- D. Remove the client's dentures from their mouth.
Correct Answer: B
Rationale: The correct answer is B: Hold the client's eyes shut for a few seconds. This action is appropriate because it helps create a peaceful appearance for the deceased client, providing a more dignified and comforting view for the family during the viewing. Holding the eyes shut is a common practice to maintain a natural appearance and show respect for the deceased.
Crossing the client's arms (Choice A) is not necessary and may not be culturally appropriate for all families. Placing the client in a high-Fowler's position (Choice C) is not recommended as it may not be comfortable or appropriate for viewing. Removing the client's dentures (Choice D) is also unnecessary and may not be respectful to the deceased.