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The oncoming nurse is receiving report on 4 clients. Which should be the priority assessment?
- A. Client who had a carotid endarterectomy that day with a blood pressure of 160/88 mm Hg
- B. Client who is 1 day post bowel resection with absent bowel sounds
- C. Client with a pulse of 109/min who has a history of atrial fibrillation
- D. Client with pancreatitis whose total parenteral nutrition is almost finished
Correct Answer: A
Rationale: Elevated blood pressure (160/88 mm Hg) post-carotid endarterectomy risks hematoma or stroke, making it the priority. Other conditions are less urgent.
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A client with AIDS treated for intractable seizures is transferred from the intensive care unit to the medical unit. There are 4 semiprivate room beds available. Which room assignment does the nurse recognize as the best option for this client?
- A. Client with Clostridium difficile
- B. Client with community-acquired pneumonia
- C. Client with fever of unknown origin
- D. Client with upper gastrointestinal bleed
Correct Answer: B
Rationale: Community-acquired pneumonia poses the least infection risk to an immunocompromised client with AIDS, unlike C. difficile or fever of unknown origin.
The nurse is caring for a client who has type 2 diabetes mellitus and an elevated hemoglobin A1c. Which statement by the nurse will best address this result?
- A. It is important for us to review the signs and symptoms of a hypoglycemic reaction.
- B. Let's review your diet, exercise, and medication regimen over the past 2-3 months.
- C. Please describe what you have eaten in the last 24-48 hours.
- D. You should fast for at least 8 hours prior to your morning blood work.
Correct Answer: B
Rationale: Elevated A1c reflects poor glycemic control over months, so reviewing diet, exercise, and medications is most relevant. Other options are less comprehensive.
The nurse is caring for a client with osteoporosis who is being discharged on alendronate (Fosamax). Which statement would indicate effective teaching?
- A. I should take the medication immediately before bedtime.
- B. I should remain in an upright position for 30 minutes after taking the medication.
- C. The medication is more effective if I take it with milk or dairy products.
- D. If I skip a dose, I can take two tablets the next time.
Correct Answer: B
Rationale: This is required to prevent esophageal problems. The medication should be taken in the morning before food or other medications with water, making answers A and C incorrect choices. It should also be taken as ordered, which makes answer D incorrect.
All of the following women are seen in the physician's office. Which is at greatest risk for preterm labor?
- A. A primigravida who has gained 30 lb during her pregnancy
- B. A 35-year-old carrying a small baby
- C. A 21-year-old pregnant with twins
- D. A 40-year-old who has four other children
Correct Answer: C
Rationale: Multiple gestation, such as twins, significantly increases preterm labor risk due to uterine overdistension, making the 21-year-old the highest risk.
The nurse is planning a staff education program about intimate partner violence. Which of the following information should the nurse include? Select all that apply.
- A. Intimate partner violence is most common in high-income families.
- B. Intimate partner violence is rare in same-sex partnerships.
- C. The abusive partner often demonstrates jealousy and possessiveness.
- D. Victims may not leave due to financial concerns or fear of harm by the abuser.
- E. Violence against a female often intensifies during pregnancy.
Correct Answer: C,D,E
Rationale: Jealousy/possessiveness, barriers to leaving (financial/fear), and increased violence during pregnancy are accurate. Violence is not limited to high-income families and occurs in same-sex partnerships.