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Which task for a client with anemia and confusion could the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Assess and document skin turgor and color changes
- B. Test stool for occult blood and urine for glucose and report results
- C. Suggest foods high in iron and those easily consumed
- D. Report mental status changes and the degree of mental clarity
Correct Answer: B
Rationale: Test stool for occult blood and urine for glucose and report results. The UAP can do standard, unchanging procedures that require no decision making.
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A woman has been recently diagnosed with systemic lupus and shares with the nurse, 'I am thinking about getting pregnant, but I don't know how I will be able to tolerate a pregnancy since I have lupus.'
- A. What is the best response by the nurse to a woman with systemic lupus considering pregnancy?
- B. Most women find that they feel better when they are pregnant.'
- C. How long have you been in remission?'
- D. Women with lupus frequently have slightly longer gestations.'
- E. It is best to become pregnant within the first six months of diagnosis.'
Correct Answer: B
Rationale: The nurse should assess the duration of remission, as women with systemic lupus erythematosus (SLE) should be in remission for at least 5 months before conceiving to minimize risks of maternal and fetal complications. Pregnancy does not typically improve SLE symptoms, gestation length is unaffected, and early pregnancy post-diagnosis is not recommended.
Which diagnosis for the client with tuberculosis would have the greatest impact on public health?
- A. Ineffective breathing pattern
- B. Deficient knowledge
- C. Fatigue
- D. Ineffective family therapeutic regimen management
Correct Answer: B
Rationale: Deficient knowledge about TB transmission risks public health by increasing spread, requiring education to ensure compliance with treatment and precautions.
The nurse is working at a student health clinic at a large university. Which of the following signs and symptoms would cause the nurse to suspect cocaine abuse in a 20-year-old college student?
- A. Frequent sneezing, complaints of a sore throat, and a temperature of 100°F (37.8°C).
- B. Diarrhea, vomiting, and abdominal pain.
- C. Fatigue, dilated pupils, and anorexia.
- D. Complaints of insomnia, rhinorrhea, and facial pain.
Correct Answer: D
Rationale: Insomnia, rhinorrhea, and facial pain are associated with cocaine inhalation, the most common administration route. Options A, B, and C are less specific: A suggests infection, B indicates GI issues, and C could apply to other substances.
An insulin-dependent diabetic is admitted with a blood sugar of 415 mg/dL. His wife states, 'He always follows his diabetic diet religiously and administers his insulin using a sliding scale twice a day.' Upon reviewing his chart, the nurse notes that the client has been hospitalized four times during the past three months for a medical diagnosis of hyperglycemia secondary to noncompliance with medical regimen. When questioned, he says, 'It's a little too complicated to keep track of when I need to eat and when I need to check my blood and take my medicine.' Which nursing diagnosis is most appropriate?
- A. Impaired adjustment
- B. Impaired home maintenance
- C. Ineffective family therapeutic regimen management
- D. Noncompliance
Correct Answer: D
Rationale: Repeated hospitalizations for hyperglycemia due to difficulty managing the regimen indicate noncompliance, the most appropriate diagnosis.
The nurse is caring for a postcholecystectomy client who had the T-tube removed this AM.
- A. What is the most appropriate action for a saturated dressing with dark, greenish-yellow drainage two hours after T-tube removal?
- B. Remove the dressing and replace it with a more absorbent dressing.
- C. Collect a culture and sensitivity specimen of the drainage.
- D. Observe the wound for dehiscence.
- E. Reinforce the dressing with an 8x10 dressing.
Correct Answer: A
Rationale: Dark, greenish-yellow drainage is expected bile after T-tube removal. Replacing the saturated dressing with a more absorbent one keeps the site clean and dry, preventing infection. Cultures are unnecessary without infection signs, dehiscence is unlikely, and reinforcing risks infection.