Nokea
Which of the following actions is the priority for the nurse to take?
- A. Evaluate the client for orthostatic hypotension.
- B. Monitor the client's urine output.
- C. Obtain the client's laboratory results.
- D. Check the client for nasal congestion
Correct Answer: A
Rationale: Orthostatic hypotension is a potential adverse effect of valsartan overdose.
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Which of the following actions should the nurse take?
- A. Assign the child to a negative air pressure room.
- B. Use droplet precautions when caring for the child
- C. Assess the child for Koplik spots
- D. Administer aspirin to the child for fever.
Correct Answer: A
Rationale: Negative pressure rooms prevent airborne spread of varicella.
A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?
- A. A client who has epidural analgesia and weakness in the lower extremities
- B. A client who has a hip fracture and a new onset of tachypnea
- C. A client who has sinus arrhythmia and is receiving cardiac monitoring
- D. A client who has diabetes mellitus and an HbA1c of 6.8%
Correct Answer: B
Rationale: The correct answer is B. The nurse should assess the client with a hip fracture and new onset of tachypnea first. Tachypnea in this client could indicate a potential complication such as a pulmonary embolism, which is a life-threatening condition requiring immediate intervention. Assessing this client first allows for prompt identification and management of any emergent issues. Clients with epidural analgesia and lower extremity weakness (choice A) may indicate a neurological concern but are not as urgent as tachypnea in a client with a hip fracture. Sinus arrhythmia with cardiac monitoring (choice C) and diabetes mellitus with an HbA1c of 6.8% (choice D) do not present immediate life-threatening situations that require immediate assessment compared to the client with a hip fracture and tachypnea.
Which of the following actions should the nurse take?
- A. Encourage the client to watch television
- B. Administer a dose of atomoxetine to decrease anxiety
- C. Teach the client how to meditate
- D. Sit with the client to provide a sense of security.
Correct Answer: D
Rationale: Providing a calming presence can help de-escalate panic symptoms.
While performing a routine assessment, a nurse notices fraying on the electrical cord of a client's continuous passive motion(CPM) device. Which of the following actions should the nurse take first?
- A. Initiate a requisition for a replacement CPM device.
- B. Report the defect to the equipment maintenance staff.
- C. Remove the device from the room.
- D. Ensure the device inspection sticker is current.
Correct Answer: C
Rationale: The correct answer is C: Remove the device from the room. The fraying electrical cord poses a serious safety hazard, risking electrical shock or fire. The first step is to remove the device to prevent harm to the client or others. Initiating a requisition (A) or reporting to maintenance staff (B) can follow, but immediate removal is crucial. Ensuring the inspection sticker is current (D) is not the priority when there is a safety issue.
Which of the following information should the nurse plan to include in the teaching?
- A. Apply petroleum jelly to soothe the mucous membranes
- B. Use synthetic fabrics for the client’s bedding
- C. Clean the equipment with an alcohol-based cleaning product.
- D. Avoid using nail polish remover around the client.
Correct Answer: D
Rationale: The correct answer is D: Avoid using nail polish remover around the client. This is important because nail polish remover contains harsh chemicals that can be harmful if inhaled or absorbed through the skin, especially for clients with compromised health conditions. Applying petroleum jelly (choice A) may not be recommended as it can trap bacteria and cause infection. Using synthetic fabrics for bedding (choice B) may not be ideal as natural fibers are more breathable and comfortable. Cleaning equipment with alcohol-based products (choice C) may not be suitable as it can be irritating to sensitive skin. Therefore, choice D is the best option for the client's safety and well-being.