Nokea
Which statement, if made by the client, indicates a possible problem?
- A. I have a bowel movement every other day.'
- B. My stools recently are black.'
- C. Sometimes I have to strain when I go to the bathroom.'
- D. I usually have three stools a day.'
Correct Answer: B
Rationale: Black stools may indicate gastrointestinal bleeding, a serious concern requiring evaluation. Other statements reflect normal variations or minor issues.
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A client comes to the emergency department with diplopia and recent onset of nausea. Which statement by the client would indicate to the nurse that this is an emergency?
- A. I am very tired, and it's hard for me to keep my eyes open.'
- B. I don't feel good, and I want to be seen.'
- C. I have not taken my blood pressure medicine in over a week.'
- D. I have the worst headache I've ever had in my life.'
Correct Answer: D
Rationale: A severe headache described as the worst ever with diplopia and nausea suggests a possible subarachnoid hemorrhage or aneurysm, requiring emergency evaluation. Other statements (A, B, C) are less specific.
A 36 year-old female client has a hemoglobin level of 14 g/dl and a hematocrit of 42% following a D&C. Which of the following would the nurse expect to find when assessing this client?
- A. Capillary refill less than 3 seconds
- B. Pale mucous membranes
- C. Respirations 20 breaths per minute
- D. Complaints of fatigue when ambulating
Correct Answer: A
Rationale: Capillary refill less than 3 seconds. Since the hemoglobin and hematocrit are normal for an adult female, additional assessments should be normal. This capillary refill time is normal.
A 72-year-old woman is being treated for pneumonia. Physician's orders include an antibiotic, oxygen PRN for O2 saturation less than 90, and pulse oximetry every 4 hours. The nurse obtains a pulse oximetry reading of 82% on room air. What is the best action for the nurse to take?
- A. Report the finding to the physician
- B. Report the finding to the registered nurse to get instructions
- C. Start supplemental oxygen
- D. Start oxygen and repeat the pulse oximetry in 20 minutes
Correct Answer: C
Rationale: An O2 saturation of 82% requires immediate supplemental oxygen per orders to correct hypoxia, the priority action.
A client is receiving oxygen therapy via a nasal cannula. When providing nursing care, which of the following interventions would be appropriate?
- A. Determine that adequate mist is supplied
- B. Inspect the nares and ears for skin breakdown
- C. Lubricate the tips of the cannula before insertion
- D. Maintain sterile technique when handling cannula
Correct Answer: B
Rationale: Inspect the nares and ears for skin breakdown. Oxygen therapy can cause drying of the nasal mucosa. Pressure from the tubing can cause skin irritation.
Which of the following statements describes what the nurse must know in order to provide anticipatory guidance to parents of a toddler about readiness for toilet training?
- A. The child learns voluntary sphincter control through repetition
- B. Myelination of the spinal cord is completed by this age
- C. Neuronal impulses are interrupted by the ganglia
- D. The toddler can understand cause and effect
Correct Answer: B
Rationale: Myelination of the spinal cord is completed by this age, enabling voluntary sphincter control between 18 to 24 months.