Nokea
The women's health charge nurse is making assignments for the next shift. The unit is short one staff member and will receive a nurse from the medical-surgical unit. Which group of clients should she assign to the medical-surgical nurse?
- A. Total abdominal hysterectomy, bladder suspension with A&P repair, client with breast reduction
- B. C-section planning discharge, post-partum infection, mastectomy
- C. Vaginal delivery of fetal demise, C-section with pneumonia, 32-week gestation with lymphoma
- D. 28-week gestation of bed rest, post-partum with HELLP syndrome, breast reconstruction
Correct Answer: A
Rationale: The correct answer includes clients who have undergone surgical procedures typically managed on a medical-surgical unit. Choice A consists of clients who have had elective surgical procedures such as hysterectomy, bladder suspension with A&P repair, and breast reduction, which are commonly treated in a medical-surgical setting. Choices B, C, and D involve clients with various complications related to childbirth, fetal demise, pneumonia, gestational lymphoma, HELLP syndrome, and bed rest, which are more complex cases requiring specialized care beyond medical-surgical nursing.
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During a school screening, a nurse notices small bruises on the anterior and posterior ribs of an 8-year-old Asian child. The nurse should ask the child:
- A. if the family practices coining
- B. who performs coinings
- C. if the child has fallen
- D. how long the child has been abused
Correct Answer: A
Rationale: The correct answer is to ask if the family practices coining. In Asian cultures, coining is a traditional practice believed to draw infections from the body. It involves rubbing a heated coin on the chest and torso, which can cause bruising similar to what the nurse noticed on the child's ribs. This question is important to differentiate between cultural practices and potential child abuse. Choices B, C, and D are incorrect because assuming abuse without considering cultural practices can lead to misinterpretation and inappropriate actions. It's crucial for healthcare providers to be culturally sensitive and gather all relevant information before making conclusions.
The nurse is making initial rounds on a client with a C5 fracture and crutch field tongs. Which equipment should be kept at the bedside?
- A. A pair of forceps
- B. A torque wrench
- C. A pair of wire cutters
- D. A screwdriver
Correct Answer: B
Rationale: A torque wrench is essential equipment to keep at the bedside for a client with a C5 fracture and crutch field tongs. This tool is used to tighten and loosen the screws of the crutch field tongs, allowing the nurse to adjust the pressure on the screws for proper support and alignment. A pair of forceps (choice A), wire cutters (choice C), and a screwdriver (choice D) are not required for managing crutch field tongs and, therefore, are incorrect choices in this scenario.
During the history assessment of an 80-year-old client, which statement made by the client might indicate a possible fluid and electrolyte imbalance?
- A. "My skin is always so dry."?
- B. "I often use a laxative for constipation."?
- C. "I have always liked to drink a lot of iced tea."?
- D. "I sometimes have a problem with dribbling urine."?
Correct Answer: B
Rationale: The correct answer is "I often use a laxative for constipation." Frequent use of laxatives can lead to diarrhea and electrolyte loss, indicating a possible fluid and electrolyte imbalance. Statements A, C, and D are not directly related to fluid and electrolyte imbalance. Statement A about dry skin may suggest dehydration, but it is less specific to electrolyte imbalance than the frequent use of laxatives. Statement C about drinking a lot of iced tea could potentially relate to fluid intake, but it doesn't directly indicate an imbalance. Statement D about dribbling urine is more indicative of a potential urinary issue rather than a fluid and electrolyte imbalance.
An elderly client denies that abuse is occurring. Which of the following factors could be a barrier for the client to admit being a victim?
- A. knowledge that elder abuse is rare
- B. personal belief that abuse is deserved
- C. lack of developmentally appropriate screening tools
- D. fear of reprisal or further violence if the incident is reported
Correct Answer: D
Rationale: One of the significant barriers for elderly clients to admit being victims of abuse is the fear of reprisal or further violence if the incident is reported. Elderly individuals may be afraid of the consequences of reporting abuse, such as retaliation or increased violence from the abuser. This fear can prevent them from disclosing their victimization. Choices A and C are incorrect as knowledge of the rarity of elder abuse and the availability of appropriate screening tools do not directly impact the client's willingness to admit abuse. Choice B, personal belief that abuse is deserved, may be a factor for some individuals but is not as common or impactful as the fear of reprisal or further violence.
The licensed practical nurse is working with a registered nurse and a patient care assistant. Which of the following clients should be cared for by the registered nurse?
- A. A client 2 days post-appendectomy
- B. A client 1 week post-thyroidectomy
- C. A client 3 days post-splenectomy
- D. A client 2 days post-thoracotomy
Correct Answer: D
Rationale: The correct answer is a client 2 days post-thoracotomy because this client is the most critical and requires the expertise of a registered nurse. Clients A and B are stable and ready for discharge after their respective surgeries (appendectomy and thyroidectomy). Client C, who is 3 days post-splenectomy, is also stable enough to be cared for by a licensed practical nurse as they are in a stable condition and do not have immediate critical needs. Therefore, the registered nurse should care for the client 2 days post-thoracotomy due to the critical nature of the procedure and the immediate postoperative care required.