Nokea
The nurse has just received report from the previous shift.
Which of the following clients should the nurse see FIRST?
- A. A client who is receiving a blood transfusion and complains of a dry mouth.
- B. A client who is scheduled to receive heparin and the PTT is 70 seconds.
- C. A client who is receiving hydroloxacin (Cipro) and complains of a high.
- D. A client who is receiving IV potassium and complains of burning at the IV site.
Correct Answer: C
Rationale: Strategy: Determine the least stable client. (1) not an immediate concern (2) PTT is within normal limits, should give medication (3) correct-indicates hypersensitivity reaction, should stop medication and notify the physician (4) should decrease rate to prevent irritation of the vein
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The nurse is supervising a student nurse teach a client about a newly prescribed medication. Which of the following actions, if observed by the nurse, would require an intervention?
- A. The student nurse glances at his/her watch when instructing the client.
- B. The student nurse uses culturally appropriate language and teaching materials.
- C. The student nurse begins instructions to the client discussing information that concerns the client.
- D. The student nurse chooses a time for teaching when there are no visitors.
Correct Answer: A
Rationale: lack of attending behaviors are always a barrier to learning
The nurse is caring for a client recently diagnosed with AIDS. Which of the following interventions by the nurse would be BEST?
- A. Inspect the skin daily for signs of breakdown.
- B. Limit the number of health care personnel caring for the patient.
- C. Utilize standard precautions when administering parenteral medications.
- D. Monitor the patient's vital signs q4h.
Correct Answer: B
Rationale: implementation, decreases exposure to microorganisms
The nurse is caring for a client with deep vein thrombosis (thrombophlebitis) of the left leg. Which of the following would be an appropriate nursing goal for this client?
- A. Decrease inflammatory response in the affected extremity and prevent embolus formation.
- B. Increase peripheral circulation and oxygenation of the affected extremity.
- C. Prepare the client and family for anticipated vascular surgery on the affected extremity.
- D. Prevent hypoxia associated with the development of a pulmonary embolus.
Correct Answer: A
Rationale: important to prevent the complication of pulmonary embolism in clients at high risk
The nurse is assisting a 58-year-old woman from the bed to the chair for the first time after a right total hip replacement. It is MOST important for the nurse to take which of the following actions?
- A. Assist the patient to stand on her right leg and pivot to a low soft chair, keeping her hips straight.
- B. Assist the patient to stand on her left leg and pivot to a straight-backed chair, flexing her hips slightly.
- C. Ask the patient to bear weight equally on both legs, bend at the waist, and sit in a low soft chair.
- D. Assist the patient to stand on both legs and take a few steps to a straight-backed chair.
Correct Answer: B
Rationale: prevents dislocation
The nurse assesses a prolonged deceleration of the fetal heart rate while the client is receiving oxytocin IV to stimulate labor. The priority nursing intervention would be to
- A. discontinue the infusion.
- B. turn client to the left side.
- C. change the fluids to LR.
- D. increase the IV flow rate.
Correct Answer: A
Rationale: will decrease contractions and thus possibly remove uterine pressure to the fetus, which is possibly cause of deceleration