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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 reinforcing instructions to a client at 34 weeks gestation who is preparing to travel by airplane. Which of the following instructions are appropriate? Select all that apply.
- A. Avoid getting up during the flight unless you need the restroom.
- B. Carry a copy of your most up-to-date prenatal record
- C. Increase fluid intake before and during the flight
- D. Secure the lap belt below the abdomen and across your hips when seated
- E. Wear compression stockings and loose-fitting clothing
Correct Answer: B,C,D,E
Rationale: Pregnant travelers should carry prenatal records for emergencies, stay hydrated to prevent dehydration, secure the lap belt safely, and wear compression stockings to reduce thrombosis risk. Avoiding movement increases clot risk, so periodic walking is recommended.
The nurse is caring for a client who just had a total thyroidectomy. Which finding does the nurse recognize as most important to report immediately?
- A. Elevated blood pressure
- B. Heart rate irregularity
- C. Low oxygen saturation
- D. Noisy breathing
Correct Answer: D
Rationale: Noisy breathing post-thyroidectomy may indicate airway obstruction from hematoma or edema, a life-threatening emergency. Other findings are less immediately critical but still require monitoring.
The licensed practical nurse is monitoring a client receiving an IV of Nipride in D5W. The IV bag has a foil covering, and the nurse notes that the IV fluid has a light brownish tint. The nurse should:
- A. Discard the solution.
- B. Obtain a bag of normal saline.
- C. Cover both the solution bag and the IV tubing with foil.
- D. Do nothing because the solution is expected to be light brown in color.
Correct Answer: D
Rationale: Nipride (nitroprusside) is light-sensitive and turns light brown, which is normal if protected by foil. No action is needed.
A nurse is teaching a class for new parents at a local community center. The nurse would stress that what is most hazardous for an 8 month-old child?
- A. Riding in a car
- B. Falling off a bed
- C. An electrical outlet
- D. Eating peanuts
Correct Answer: D
Rationale: Eating peanuts. Asphyxiation due to foreign materials in the respiratory tract is the leading cause of death in children younger than 6 years of age.
The nurse is planning care for a group of senior citizens. The nurse should plan activities that promote achievement of which developmental task?
- A. Identity
- B. Intimacy
- C. Generativity
- D. Ego integrity
Correct Answer: D
Rationale: Ego integrity, accepting one's life as meaningful, is the developmental task for seniors per Erikson's theory. Identity, intimacy, and generativity apply to younger stages.