Nokea
The nurse is caring for patients on the surgical floor and has just received report from the previous shift.
Which of the following patients should the nurse see FIRST?
- A. A 35-year-old admitted three hours ago with a gunshot wound; 1/5 cm area of dark drainage noted on the dressing.
- B. A 43-year-old who had a mastectomy two days ago; 23 cc of serosanguinous fluid noted in the Jackson-Pratt drain.
- C. A 59-year-old with a collapsed lung due to an accident; no drainage noted from chest tube in last eight hours.
- D. A 62-year-old who had an abdominal-perineal resection three days ago; patient complains of chills.
Correct Answer: D
Rationale: Strategy: Think ABCs. (1) does not indicate acute bleeding, small amount of blood (2) expected outcome (3) indicates resolution (4) correct-risk for peritonitis, should be assessed for further symptoms of infection
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A client comes to the clinic complaining of severe facial pain. In order to collect subjective data from the client, it is MOST important for the nurse to
- A. obtain the client's vital signs.
- B. interview the client.
- C. inspect the face for grimacing.
- D. administer pain medication.
Correct Answer: B
Rationale: subjective data is collected in the health history or interview
A group of senior citizens.
The nurse teaches a health class at the local library to a group of senior citizens. Which of the following behaviors should the nurse emphasize to facilitate regular bowel elimination?
- A. Avoid strenuous activity.
- B. Eat more foods with increased bulk.
- C. Decrease fluid intake to decrease urinary losses.
- D. Use oral laxatives so that a bowel pattern emerges.
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) regular exercise program facilitates bowel elimination (2) correct-contained in whole grains, legumes, vegetables, fruits, seeds, nuts, bulk promotes peristalsis (3) normal fluid intake of 1,500 cc/day facilitates bowel elimination (4) laxatives used as last resort because they become habit-forming
The nursing staff is planning to use behavior modification techniques for an elderly woman who constantly screams. Which of the following nursing assessments is necessary to establish a successful program?
- A. Monitor the client's ability to complete her activities of daily living (ADL).
- B. Assess the client's levels of pain and correlate it with her response to analgesia.
- C. Observe the client's behavior at regular intervals to obtain baseline information related to her screaming.
- D. Ask the client why she is screaming and document it on her nursing assessment record.
Correct Answer: C
Rationale: to design an effective behavior modification program, accurate baseline data must first be collected about the target behavior in relation to frequency, amount, time, and precipitating factors
The nurse is observing a student nurse auscultate the lungs of a client. The nurse knows that the student nurse is correctly auscultating the right middle lobe (RML) if the stethoscope is placed in which of the following positions?
- A. Posterior and anterior base of right side.
- B. Right anterior chest between the fourth and sixth intercostals.
- C. Left of the sternum, midclavicular, at right fifth intercostal.
- D. Posterior chest wall, midaxillary, right side.
Correct Answer: B
Rationale: RML is found in the right anterior chest between the fourth and sixth intercostal spaces
The nurse is preparing to administer insulin to a client with type I diabetes.
- A. Which action should the nurse take first before administering insulin to a client with type I diabetes?
- B. Verify the insulin dose with another nurse.
- C. Check the client’s blood glucose level.
- D. Cleanse the injection site with alcohol.
- E. Rotate the injection site from the previous dose.
Correct Answer: B
Rationale: Checking the client’s blood glucose level is the first step to ensure the insulin dose is appropriate, preventing hypo- or hyperglycemia. Verifying the dose, cleansing the site, and rotating sites are important but follow glucose confirmation.