Nokea
While preparing to change the dressing of a female patient with end-stage renal disease, the nurse notices that the patient's son is silently holding her hand and praying. Which of the following should be the nurse's initial action?
- A. Continue preparing for the procedure in the room.
- B. Notify the chaplain.
- C. Leave the room quietly and come back after 15 minutes to change the client's dressing.
- D. Ask the son if he wants the nurse to join in prayer.
Correct Answer: C
Rationale: Respecting the spiritual moment, leaving the room quietly allows privacy and maintains dignity.
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The nurse in the emergency department (ED) is caring for a 10-year-old client.
Item 2 of 5
Nurses' Notes
1322: 10-year-old client and his parents report an 8-day history of a brownish-raised lesion over the back of his left leg. The parents report that the size of the rash has increased. The parents report returning from a one-week camping trip three weeks ago. The parents deny efficacy with over-the-counter antihistamine creams. The client's parents deny that the child has had a fever but has felt 'warm' occasionally and endorsed an intermittent headache. They report an area of firmness in the child's groin. On assessment, there was an erythematous, raised, nonpainful, oval patch on the back of his left leg. This was an enlargement of an inguinal lymph node. The child is alert and fully oriented and denies any pain. Peripheral pulses palpable 2+. No cyanosis or edema in the extremities. Lung sounds clear bilaterally. The parents report that the child did not receive the seasonal influenza vaccine. He currently takes a multivitamin for iron deficiency anemia and was hospitalized one year ago for an appendectomy. The parents state that the child’s sibling had influenza one month ago. Vital signs: T 98.8°F (37.1°C); HR 78 beats/min; RR 16 breaths/min; BP 110/76 mm Hg. SpO2 97% on room air.
The nurse considers if the client may have an infection caused by a tick. Click to specify if the features are consistent with the disease process of Rocky Mountain spotted fever (RMSF) or Lyme Disease.
- A. Fever
- B. Petechial rash that becomes diffuse
- C. Erythema migrans (bullseye rash)
- D. Myalgia
- E. Causative agent Rickettsia rickettsii
- F. Causative agent Borrelia burgdorferi
Correct Answer: C (Lyme Disease), F (Lyme Disease)
Rationale: The bullseye rash and Borrelia burgdorferi are specific to Lyme disease. Fever and myalgia can occur in both RMSF and Lyme disease, but the petechial rash and Rickettsia rickettsii are specific to RMSF.
The nurse is caring for a pregnant client at 28 weeks' gestation who presents to the emergency department with signs of preeclampsia. The primary healthcare provider (PHCP) orders magnesium sulfate. What potential complication should the nurse closely monitor for during magnesium sulfate administration?
- A. Pulmonary edema
- B. Hyperglycemia
- C. Hyporeflexia
- D. Increased fetal movement
Correct Answer: C
Rationale: Hyporeflexia is a sign of magnesium toxicity, a critical complication to monitor during administration.
The nurse is providing teaching to a client experiencing chronic constipation. Which of the following meals would be the best choice for this client in order to promote a bowel movement?
- A. steak and a baked potato
- B. brussels sprouts and a whole grain roll
- C. white rice with chicken
- D. ham sandwich with tomato soup
Correct Answer: B
Rationale: Brussels sprouts and whole grain rolls are high in fiber, promoting bowel movements.
The nurse has attended a continuing education presentation about acid-base imbalances. It would indicate a correct understanding of the conference if the nurse identifies which of the following conditions may cause the ABG in the exhibit.
- A. Five-day history of severe diarrhea
- B. Hyperemesis gravidarum
- C. End-stage renal disease (ESRD)
- D. Diabetic ketoacidosis (DKA)
- E. Chronic obstructive pulmonary disease (COPD)
- F. Hyperglycemic hyperosmolar nonketotic syndrome (HHNS)
Correct Answer: A, B, D, F
Rationale: Severe diarrhea, hyperemesis gravidarum, DKA, and HHNS can cause metabolic acidosis, as indicated by a low pH and low bicarbonate on ABG.
The nurse is caring for a client three hours postpartum after delivering a term newborn infant. Which assessment finding would indicate an early sign of postpartum hemorrhage?
- A. Heart rate change from 80 to 125 bpm
- B. Blood pressure change from 125/90 to 119/82 mmHg
- C. A decrease in respiratory rate from 22 to 16 breaths per minute
- D. Saturation of one peri-pad since delivery
Correct Answer: A
Rationale: Tachycardia (heart rate increase to 125 bpm) is an early sign of postpartum hemorrhage due to compensatory response to blood loss.