Nokea
While documenting in a client's medical record, which of the following entries should the nurse record?
- A. "Incision without redness or drainage"
- B. "Drank adequate amounts of fluid with meals"
- C. "Administered pain medication"
- D. "Oral temperature slightly elevated at 0800"
Correct Answer: D
Rationale: The correct answer is D because documenting specific observations, such as an oral temperature being slightly elevated at a specific time, is crucial for monitoring the client's health status accurately. This type of information helps in assessing trends and changes in the client's condition over time. Choice A is incorrect as it lacks specificity and does not provide measurable data about the client's condition. Choice B is incorrect because it is a general statement related to client behavior rather than a specific health observation. Choice C is incorrect as it reflects an action taken by the nurse and not a direct client's condition or observation.
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A healthcare professional is preparing to administer lactated Ringer's (LR) IV 100 mL over 15 min. How many mL/hr should the IV infusion pump be set to deliver? (Round the answer to the nearest whole number. Do not use a trailing zero.)
- A. 400 mL/hr
- B. 200 mL/hr
- C. 300 mL/hr
- D. 250 mL/hr
Correct Answer: A
Rationale: To administer 100 mL over 15 min, the IV pump should be set to deliver 400 mL/hr. This calculation is based on the concept that if 100 mL is given in 15 minutes, to find out how many milliliters are given in an hour, you would multiply by 4 (since 15 minutes is a quarter of an hour). Therefore, 100 mL x 4 = 400 mL per hour. Choices B, C, and D are incorrect as they do not reflect the correct calculation for the infusion rate required to administer 100 mL over 15 minutes.
When is a depressed client at highest risk for attempting suicide?
- A. Immediately after admission, during one-to-one observation
- B. 7 to 14 days after initiation of antidepressant medication and psychotherapy
- C. Following an angry outburst with family
- D. When the client is removed from the security room
Correct Answer: B
Rationale: Depressed clients are at the highest risk of attempting suicide 7 to 14 days after starting antidepressant medication and psychotherapy. During this time, they may start to regain energy but still feel hopeless, which can increase the risk of suicidal ideation and behavior. Choices A, C, and D are incorrect because immediate post-admission, after an angry outburst with family, or when removed from a security room are not specific periods known to be associated with the highest risk of suicide in depressed clients.
While changing a client's postoperative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given there is a positive MRSA, which is the most important action for the nurse to take?
- A. Force oral fluids
- B. Request a nutrition consult
- C. Initiate contact precautions
- D. Limit visitors to immediate family only
Correct Answer: C
Rationale: The correct action for the nurse to take in this situation is to initiate contact precautions. MRSA (Methicillin-resistant Staphylococcus aureus) is a highly contagious bacterium that spreads through direct contact. Contact precautions involve wearing gloves and gowns to prevent the spread of infection to other patients or healthcare workers. Force-feeding oral fluids, requesting a nutrition consult, or limiting visitors to immediate family only are not the most appropriate actions in this scenario. These actions do not directly address the need to prevent the spread of MRSA, which is crucial in a healthcare setting.
The nurse is caring for a client with a urinary tract infection (UTI). Which finding should the LPN/LVN report to the healthcare provider immediately?
- A. Cloudy urine
- B. Burning sensation during urination
- C. Foul-smelling urine
- D. Blood in the urine
Correct Answer: D
Rationale: The presence of blood in the urine in a client with a urinary tract infection (UTI) may indicate a more severe infection, such as pyelonephritis, or complications like kidney stones or bladder cancer. Therefore, this finding should be reported immediately for further evaluation and management. Cloudy urine, burning sensation during urination, and foul-smelling urine are common symptoms of UTI and may not necessarily signify an urgent need for immediate reporting compared to the presence of blood in the urine.
A parent asks a nurse about his infant's expected physical development during the first year of life. Which of the following information should the nurse include?
- A. A 10-month-old infant can pull up to a standing position.
- B. A 6-month-old infant can walk with assistance.
- C. A 12-month-old infant can jump with both feet.
- D. An 8-month-old infant can crawl on hands and knees.
Correct Answer: A
Rationale: The correct answer is A. By 10 months, infants can typically pull up to a standing position as part of their physical development. Walking with assistance usually begins around 9-12 months, not at 6 months (choice B). Jumping with both feet is a skill that usually develops around 24 months, not at 12 months (choice C). Crawling on hands and knees typically starts around 6-9 months, not at 8 months (choice D). Therefore, the most accurate information to include for an infant's expected physical development at 10 months is the ability to pull up to a standing position.