Nokea
The nurse has just returned to the desk and has four phone messages to return.
Which of the following messages should the nurse return FIRST?
- A. A man with swelling of his left wrist following a fall from a ladder two hours ago.
- B. A woman who had a cholecystectomy one week ago and now complains of redness and tenderness at the incision site.
- C. A mother of a child reports that her son's lips are swollen following a fire ant bite.
- D. A man with COPD reports he is coughing up large amounts of green-tinged sputum and has a temperature of 101.2°F (38.4°C).
Correct Answer: C
Rationale: Strategy: Remember the ABCs. (1) wrist needs to be x-rayed, not a priority (2) indicates infection, treated with antibiotic (3) correct-potential anaphylactic reaction, administer epinephrine, corticosteroids; treat for shock (4) indicates infection, treat with an antibiotic
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The nurse is teaching a client with a new diagnosis of gout about allopurinol (Zyloprim). Which of the following statements by the client indicates a need for further teaching?
- A. I should drink plenty of water while taking this medication.
- B. I should report a rash to my doctor.
- C. I should take this medication with food.
- D. I should stop this medication if my gout attacks stop.
Correct Answer: D
Rationale: Stopping allopurinol when gout attacks stop is incorrect, as it is used long-term to prevent uric acid buildup. Options A, B, and C are correct: water prevents kidney stones, rash may indicate hypersensitivity, and food reduces GI upset.
A 69-year-old woman has been receiving total parenteral nutrition (TPN) for several weeks. If the TPN were abruptly discontinued, the nurse would expect the patient to exhibit
- A. tinnitus, vertigo, blurred vision.
- B. fever, malaise, anorexia.
- C. diaphoresis, confusion, tachycardia.
- D. hyperpnea, flushed face, diarrhea.
Correct Answer: C
Rationale: insulin levels remain high while glucose levels decline; results in hypoglycemia; will also see restlessness, headache, weakness, irritability, apprehension, lack of muscle coordination
The nurse is caring for a client who is 4 days post-op for a transverse colostomy. The client is ready for discharge and asks the nurse to empty his colostomy pouch. What is the best response by the nurse?
- A. You should be emptying the pouch yourself.'
- B. Let me demonstrate to you how to empty the pouch.'
- C. What have you learned about emptying your pouch?'
- D. Show me what you have learned about emptying your pouch.'
Correct Answer: D
Rationale: Most adult learners obtain skills by participating in the activities. Anxiety about discharge can be causing the client to forget that they have mastered the skill of emptying the pouch. The client should show the nurse how the pouch is emptied.
The home care nurse is instructing a client recently diagnosed with tuberculosis.
- A. What is the most important instruction for a client with tuberculosis?
- B. During the first two weeks of treatment, the client should cover his mouth and nose when he coughs or sneezes.
- C. It is necessary for the client to wear a mask at all times to prevent transmission of the disease.
- D. The family should support the client to help reduce feeling of low self-esteem and isolation.
- E. The client will be required to take prescribed medication for a duration of 6-9 months.
Correct Answer: D
Rationale: Adherence to a 6-9 month medication regimen is critical to cure tuberculosis and prevent drug resistance. While respiratory precautions, family support, and masks are important, long-term medication compliance is the most essential for treatment success.
An infant is admitted for vomiting and diarrhea. The infant's anterior fontanelle is depressed, and he has a fever of 103.2°F (39.5°C).
Which of the following nursing actions would be MOST appropriate?
- A. Determine daily weights and evaluate weight loss.
- B. Evaluate infant's ability to take in fluids.
- C. Place a full bottle of Pedi-Lyte at the bedside.
- D. Start an intravenous infusion.
Correct Answer: B
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes. (1) assessment, correct information, but is not what the question asks for (2) correct-assessment, will assist in determining if hydration can be done through oral fluids alone (3) implementation, does not do anything to improve the situation; placing a full bottle at the bedside doesn't guarantee that the infant is taking fluids (4) implementation, would be implemented later