Nokea
The nurse's aide comes to take a woman by wheelchair for a magnetic resonance imaging (MRI) scan of the head and neck.
Which of the following observations, if made by the nurse, would require an intervention?
- A. The woman removes her dentures and gives them to her husband.
- B. The woman's vital signs are: BP 120/70, pulse 80, respirations 12, temperature 99°F (37.3°C).
- C. The woman has a nitroglycerine patch on her right chest area.
- D. The woman has red nail polish on her fingers and toes.
Correct Answer: C
Rationale: Strategy: 'Require an intervention' indicates an incorrect action. (1) should be removed before the Test (2) results are within normal limits (3) correct-should be removed before the Test (4) unnecessary to check capillary refill
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The nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following laboratory results should the nurse monitor closely?
- A. Serum potassium and glucose.
- B. Serum cholesterol and triglycerides.
- C. Serum calcium and magnesium.
- D. Serum sodium and chloride.
Correct Answer: A
Rationale: TPN can cause hyperglycemia and hypokalemia; monitoring potassium and glucose is critical. Options B, C, and D are less immediately relevant.
The nurse is teaching a client with a new diagnosis of hypothyroidism about levothyroxine (Synthroid). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this medication in the morning.
- B. I should report chest pain to my doctor.
- C. I should avoid taking this with calcium supplements.
- D. I should stop this medication if I feel better.
Correct Answer: D
Rationale: Stopping levothyroxine when feeling better is incorrect, as hypothyroidism requires lifelong replacement therapy to maintain euthyroid status. Options A, B, and C are correct: morning dosing minimizes insomnia, chest pain may indicate overdose, and calcium supplements interfere with absorption.
The nurse knows which of the following would be MOST likely to help the family of an emotionally disturbed client manage behaviors at home after discharge from inpatient treatment?
- A. Refer the family to Alliance for the Mentally Ill meetings for educational programs and support groups.
- B. Provide the family with pamphlets that describe the desired action and side effects of medications the client is taking.
- C. Tell the family that it is not their fault that the client behaves inappropriately.
- D. Involve the family in the assessment of the client when s/he is first admitted to the hospital.
Correct Answer: A
Rationale: The Alliance for the Mentally Ill offers ongoing education and support groups, equipping families with skills to manage behaviors long-term. Pamphlets, reassurance, and early involvement are helpful but lack the sustained impact of a support network.
The nurse who is the primary caregiver for an adult client receives a telephone report from the Microbiology Department that the client's blood culture is positive for gram-negative rods. The client is not on antibiotics. What should the nurse do first?
- A. Document the result in the appropriate area of the chart
- B. Inform the client that the nurse now knows what is causing his illness
- C. Place a call to the physician and document the results of the lab work and the notification of the physician in the nurse's notes
- D. Place the laboratory report on the client's chart as soon as possible
Correct Answer: C
Rationale: Notifying the physician promptly ensures timely antibiotic initiation for a positive blood culture, the priority action.
A six-year-old boy with a history of epilepsy admitted with uncontrolled seizures.
It is MOST important for the nurse to ask which of the following questions?
- A. What part of the body was affected by the seizure?'
- B. What is the family history of seizure disorders?'
- C. What was your son doing before the seizure?'
- D. How long has it been since his last episode of seizures?'
Correct Answer: C
Rationale: Strategy: 'MOST important' indicates that this is a priority question. (1) not most important question (2) should be included in detailed history, but will not prevent an immediate reoccurrence (3) correct-seizure may result from triggering mechanism (loud noise, music, flickering light, prolonged reading, drugs) (4) should be included in detailed history, but will not prevent an immediate reoccurrence