Nokea
The nurse has just received report from the previous shift.
Which of the following patients should the nurse see FIRST?
- A. An elderly woman, 8-hours postoperative, following an open-reduction and internal fixation of the right hip.
- B. An elderly man admitted 4 hours ago with status asthmaticus.
- C. A middle-aged man admitted 2 days ago with pneumonia who has a temperature of 101.2°F (38.4°C).
- D. A middle-aged woman who suffered a myocardial infarction (MI) 3 days ago.
Correct Answer: B
Rationale: Strategy: Determine the least stable client. (1) leg needs to be abducted at all times, ice to operative site, turn patient as ordered (2) correct-life-threatening condition which can last longer than 24 hours, constantly monitor client (3) requires follow-up, assess breath sounds (4) monitor vital signs, I and O, teach to modify lifestyle (stop smoking, reduce stress, modify intake of calories, fat, and salt)
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The nurse is teaching a client with newly diagnosed diabetes mellitus about foot care. Which of the following instructions should the nurse include?
- A. Soak feet in hot water daily.
- B. Apply lotion between the toes.
- C. Trim toenails with rounded edges.
- D. Inspect feet daily for cuts or sores.
Correct Answer: D
Rationale: Daily foot inspection prevents complications like infections in diabetes. Options A, B, and C risk burns, fungal growth, or ingrown nails.
The nurse is conducting a community group discussion on nutrition. One of the participants says to the nurse, 'I am a vegan. I have been told I might get pernicious anemia. How can I prevent that?' What should the nurse include when answering the client?
- A. She is not at risk for pernicious anemia because there are many nonmeat sources of vitamin B12.
- B. She is at risk of developing pernicious anemia, but taking a vitamin supplement that contains vitamin B12 should prevent it.
- C. She should see her physician and ask about getting monthly injections of vitamin B12 because she is a risk for pernicious anemia.
- D. She should be tested for an enzyme that produces vitamin B12. If she is deficient, she should be treated with daily injections.
Correct Answer: B
Rationale: Vegans lack dietary B12 (found in animal products), risking pernicious anemia. Oral B12 supplements can prevent deficiency, while injections or enzyme testing are unnecessary unless absorption issues exist.
A child with epiglottitis.
Which of the following nursing observations would indicate to the nurse that a child with epiglottitis is having an early complication of hypoxemia?
- A. Heart rate of 148 beats per minute.
- B. Bluish discoloration of the skin.
- C. Bluish discoloration around the mouth.
- D. Difficulty swallowing.
Correct Answer: A
Rationale: Strategy: Determine how each answer choice relates to epiglottitis. (1) correct-heart rate correlates with hypoxemia and is an early finding, along with restlessness (2) cyanosis, late sign (3) circumoral cyanosis, late sign (4) sign of epiglottitis
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.
Which individual is at greatest risk for developing hypertension?
- A. 45 year-old African American attorney
- B. 60 year-old Asian American shop owner
- C. 40 year-old Caucasian nurse
- D. 55 year-old Hispanic teacher
Correct Answer: A
Rationale: 45 year-old African American attorney. The incidence of hypertension is greater among African Americans than other groups in the US. The incidence among the Hispanic population is rising.