Nokea
The practical nurse is assisting the registered nurse in assessing a child with attention-deficit hyperactivity disorder at the clinic for a well-child visit. The client has been taking methylphenidate for a year. What are the priority nursing assessments?
- A. Attention span and activity level
- B. Dental health and mouth dryness
- C. Height/weight and blood pressure
- D. Progress with schoolwork and in making friends
Correct Answer: C
Rationale: Methylphenidate can affect growth (height/weight) and increase blood pressure (C), making these priority assessments. Attention and activity (A) are relevant but secondary. Dental health (B) and social progress (D) are less critical for medication monitoring.
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The nurse receives the handoff of care report on four clients. Which client should the nurse see first?
- A. Client reporting incisional pain of 8 on a scale of 0-10 with a respiratory rate of 25/min who had a right pneumonectomy 12 hours ago
- B. Client with a left pleural effusion who has crackles, absent breath sounds in the left base, and an SpO2 of 94% on room air
- C. Client with a temperature of 100.4 F (38 C) and a respiratory rate of 12/min who had a small bowel resection 1 day ago
- D. Client with pneumonia who has a temperature of 97.6 F (36.4 C), has an SpO2 of 93% on 4 L/min supplemental oxygen, and is becoming restless
Correct Answer: D
Rationale: Restlessness in a pneumonia client with low SpO2 (D) suggests worsening hypoxia, requiring immediate assessment. Severe pain (A) is urgent but stable. Pleural effusion (B) and fever (C) are less critical.
The nurse can best ensure the safety of a client suffering from dementia who wanders from the room by which action?
- A. Repeatedly remind the client of the time and location
- B. Explain the risks of walking with no purpose
- C. Use protective devices to keep the client in the bed or chair in the room
- D. Attach a wander-guard sensor band to the client's wrist
Correct Answer: D
Rationale: This type of identification band easily tracks the client's movements and ensures safety while the client wanders on the unit. Restriction of activity is inappropriate for any client unless they are potentially harmful to themselves or others.
The nurse is caring for a client who is receiving peritoneal dialysis and is reporting chills and abdominal discomfort. The nurse notes rebound tenderness with palpation. Which of the following actions would be a priority for the nurse to take?
- A. Discontinue the exchange and collect a peritoneal fluid specimen for culture and sensitivity.
- B. Warm the remaining dialysate fluid and increase the dwell time of the exchange.
- C. Administer a dose of oxycodone prescribed PRN for the client.
- D. Place the client in the high-Fowler position in bed.
Correct Answer: A
Rationale: Chills, discomfort, and rebound tenderness suggest peritonitis, requiring fluid culture (A). Warming dialysate (B), pain medication (C), and positioning (D) do not address the infection.
A client with emphysema visits the clinic. While teaching about proper nutrition, the nurse should emphasize that the client should
- A. Eat foods high in sodium to increase sputum liquefaction
- B. Use oxygen during meals to improve gas exchange
- C. Perform exercise after respiratory therapy to enhance appetite
- D. Cleanse the mouth of dried secretions to reduce risk of infection
Correct Answer: B
Rationale: Use oxygen during meals to improve gas exchange. This supports breathing and energy needs during eating.
The nurse caring for a terminally ill client asks if the client has an advance directive. The client states, 'I already have a power of attorney.' What is the best response by the nurse?
- A. A power of attorney (POA) is good to have in place. It sounds like you are on the right track.
- B. Great. Your POA can start to make decisions for you when you are no longer able to do so.
- C. Many people find a lawyer at this stage of life. A lawyer can help you get your affairs in order.
- D. There are many types of POAs. Let's clarify if your POA can make health care decisions for you.
Correct Answer: D
Rationale: Clarifying if the POA includes healthcare decisions (D) ensures proper advance directive planning. Vague affirmations (A, B) or suggesting a lawyer (C) do not address the need for a healthcare-specific POA.