Nokea
The unit secretary notifies the nurse that 4 clients called the nurses' station reporting pain. Which client should the nurse assess first?
- A. Client who had a foot amputation today reporting left shoulder pain radiating down the arm
- B. Client who has acute pancreatitis reporting severe, continuous, penetrating abdominal pain
- C. Client who has multiple myeloma reporting deep pelvic pain after walking down the hall
- D. Client who has sickle cell disease reporting severe pain in the arms and upper back
Correct Answer: A
Rationale: Shoulder pain radiating down the arm post-amputation suggests a possible cardiac event (e.g., angina), a life-threatening condition requiring immediate assessment. Other pains, while severe, are more likely related to known conditions.
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The nurse is reviewing discharge instructions with a client going home on linezolid therapy for a vancomycin-resistant enterococcus infection. Which client statement requires further teaching?
- A. I can restart my paroxetine once I get back home.
- B. I can take acetaminophen for headaches.
- C. I will avoid foods and drinks that contain tyramine.
- D. I will report any increased fever or diarrhea.
Correct Answer: A
Rationale: Linezolid interacts with SSRIs like paroxetine, risking serotonin syndrome, requiring a washout period. Acetaminophen is safe, tyramine avoidance prevents hypertensive crises, and reporting fever/diarrhea monitors treatment response.
The practical nurse and the charge nurse work together to assign a semi-private room to a client with diabetes mellitus admitted for IV antibiotic therapy to treat argumentative cellulitis. Which of the 4 room assignments is the best option for this client?
- A. Room 1: Client 1 day postoperative laparoscopic cholecystectomy who is awaiting discharge
- B. Room 2: Client with dementia and urinary incontinence wearing an external urine collection device
- C. Room 3: Client with history of splenectomy 15 years ago, now admitted for pulmonary embolism
- D. Room 4: Client with lupus nephritis who is prescribed treatment with azathioprine
Correct Answer: A
Rationale: The postoperative client in Room 1 is stable and awaiting discharge, posing the least risk of complications or infection to the client with cellulitis. Other roommates have conditions (dementia, embolism, immunosuppression) that could complicate care or increase infection risk.
The nurse has delegated care of a client who is very hard of hearing to an unlicensed person. Which of the following would be the least helpful information to give to the unlicensed person to better facilitate communications with the client?
- A. Reduce background noise.
- B. Adjust the hearing aid.
- C. Anticipate what the client may say and finish the statement for the client.
- D. Face the client when speaking to the client.
Correct Answer: C
Rationale: Anticipating and finishing statements risks miscommunication and frustration, least helpful for effective communication with a hearing-impaired client.
The nurse is preparing to administer insulin aspart subcutaneously at 0700 to a client with type 1 diabetes mellitus. Which of following actions would be a priority for the nurse to take?
- A. Choose a site on the clients arm for the injection
- B. Give the client breakfast within 15 minutes
- C. Recheck the capillary blood glucose level in 1 hour
- D. Reinforce teaching about signs and symptoms of hyperglycemia
Correct Answer: B
Rationale: Insulin aspart is rapid-acting, peaking within 1-3 hours. Administering it at 0700 requires breakfast within 15 minutes to prevent hypoglycemia. Site selection is routine, rechecking glucose later is secondary, and teaching is not urgent.
The nurse caring for multiple clients on a medical-surgical unit should delegate which action to the nursing assistant?
- A. Assist client, post hip fracture repair, to the bathroom
- B. Check the appearance of client's wound
- C. Discontinue nasogastric tube if client tolerates oral liquids
- D. Offer orange juice to client if bedside glucose reading is <70 mg/dL (3.9 mmol/L)
Correct Answer: A
Rationale: Assisting with mobility, such as to the bathroom, is within the nursing assistant's scope. Wound assessment, tube discontinuation, and treating hypoglycemia require nursing judgment and are outside their scope.