Nokea
Which clients can be assigned to share the same room?
- A. The client scheduled for a hysterectomy and the client with a tubal ligation
- B. The client with pneumonia and the client just returned from having a cardiac catheterization
- C. The client with AIDS and the client with bronchiectasis
- D. The client with rheumatoid arthritis being treated with steroids and the client with emphysema
Correct Answer: A
Rationale: Clients with hysterectomy and tubal ligation are both post-surgical, non-infectious, and suitable to share a room. Other pairs involve infectious or immunocompromised conditions, posing risks.
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A client on a psychiatric unit is glaring across the room and pointing a finger at empty space and yelling. What is the nurse's best response to the client's behavior?
- A. Say to him, 'There is no one there. Keep your voice down.'
- B. Escort the client to his room
- C. Restrain the client
- D. Offer PRN haloperidol (Haldol) as ordered
Correct Answer: B
Rationale: Escorting the client to a quieter space de-escalates agitation and ensures safety, addressing potential psychosis calmly.
The nurse is bathing a client who has contact isolation ordered. The nurse wears gloves. What else is needed?
- A. Face mask
- B. Sterile gloves
- C. Isolation cap
- D. Isolation gown
Correct Answer: D
Rationale: An isolation gown prevents contact transmission, required alongside gloves for bathing a client in contact isolation.
A client with a hiatal hernia.
A nursing assessment of a client with a hiatal hernia is MOST likely to reveal
- A. a bulge in the lower right quadrant.
- B. pain at the umbilicus radiating down into the groin.
- C. a burning sensation in the midepigastric area each day before lunch.
- D. complaints of awakening at night with heartburn.
Correct Answer: D
Rationale: Strategy: Think about each answer choice. (1) suggests an inguinal hernia (2) suggests an inguinal hernia (3) pain usually does not develop during the day with an empty stomach (4) correct-classic symptom of hiatal hernia associated with reflux
The client is admitted to the intensive care unit with severe chest pain. Which information provides the nurse with the most data that can be utilized in planning care?
- A. The blood pressure
- B. The vital signs
- C. The pulse oximeter
- D. The EEG
Correct Answer: B
Rationale: Vital signs include blood pressure, pulse, respirations, and temperature, providing the most comprehensive data for planning care in a client with severe chest pain. Blood pressure and pulse oximeter are included in vital signs, and EEG is irrelevant for chest pain.
Which of the following findings is associated with right-sided heart failure?
- A. Shortness of breath
- B. Nocturnal polyuria
- C. Daytime oliguria
- D. Crackles in the lungs
Correct Answer: B
Rationale: Nocturnal polyuria occurs in right-sided heart failure due to fluid redistribution at night. Shortness of breath and crackles are more typical of left-sided failure. Oliguria is not specific.