Nokea
A nursing assistant is assigned to constant observation of a suicidal patient.
Which of the following statements made by the nursing assistant would require IMMEDIATE intervention by the nurse?
- A. Let's put your clothes in the dresser.'
- B. I'll stay in the bathroom with you while you take your shower.'
- C. You're going to be moved to a private room later today.'
- D. I'll be right back with something for you to eat.'
Correct Answer: D
Rationale: Strategy: 'Require IMMEDIATE intervention' indicates that something is wrong. (1) no reason to intervene (2) appropriate, client is not to be left alone for any reason (3) no reason to intervene (4) correct-client under constant observation; must not be left alone for any reason
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An adult is hospitalized for heart failure. Hydrochlorothiazide and digoxin are prescribed. What laboratory test(s) should the nurse monitor because the client is taking these medications?
- A. CBC and differential
- B. Serum creatinine and BUN
- C. Cardiac enzymes
- D. Serum electrolytes
Correct Answer: D
Rationale: Hydrochlorothiazide and digoxin can cause electrolyte imbalances (e.g., hypokalemia), increasing digoxin toxicity risk, necessitating serum electrolyte monitoring.
The nurse is caring for an adult who had a nephrectomy this morning. Because of the location of the surgery, the nurse knows that the client is at increased risk for which of the following?
- A. Thrombophlebitis
- B. Wound infection
- C. Atelectasis
- D. Footdrop
Correct Answer: C
Rationale: Nephrectomy involves flank incision near the diaphragm; postoperative pain limits deep breathing, increasing atelectasis risk. Thrombophlebitis, infection, or footdrop are less specific to the site.
The nurse is caring for a client after dental surgery. The dentist has prescribed ibuprofen (Motrin IB) 600 mg PO. The nurse would be MOST concerned if the client made which of the following statements?
- A. I was treated for a peptic ulcer two years ago.
- B. I had a transurethral resection of the prostate (TURP) last year.
- C. I attend Weight Watchers.
- D. I have been having problems with gout.
Correct Answer: A
Rationale: Ibuprofen risks gastroinTest inal bleeding in clients with a peptic ulcer history. Options B, C, and D are not contraindications.
The nurse is caring for a client who is terminally ill. Upon admission, the client signed advance directives indicating that she does not wish to have any resuscitative measures. The client is now in and out of consciousness. Her daughter comes to the nurse and says, 'I want everything done for my mother if she stops breathing.' How should the nurse respond?
- A. Remove the 'Do Not Resuscitate' order from the chart.
- B. Discuss the client's advance directives with the daughter.
- C. Have the daughter sign a consent form since her mother is in and out of consciousness.
- D. When the client is conscious, ask her again what her wishes are.
Correct Answer: B
Rationale: Discussing advance directives respects the client's documented wishes, clarifying the DNR order with the daughter to ensure alignment.
A four-year-old is admitted with drooling and an inflamed epiglottis. During the assessment, the nurse would identify which of the following symptoms as indicative of an increase in respiratory distress?
- A. Bradycardia.
- B. Tachypnea.
- C. General pallor.
- D. Irritability.
Correct Answer: B
Rationale: increase in the respiratory rate is an early sign of hypoxia, also for tachycardia