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While reviewing the chart of an elderly client, the nurse notes that the last recorded temperature for the preceding shift was 104°. There is no documented intervention. The nurse should:
- A. Check the doctor's orders for an antipyretic.
- B. Ask the client whether he has received any medication for his fever.
- C. Call the nurse at home to validate whether the medication was given.
- D. Retake the client's temperature.
Correct Answer: D
Rationale: Retaking the temperature verifies the current status, as the fever may have resolved. Checking orders or asking the client assumes the fever persists, and calling the nurse is impractical.
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The primary nursing diagnosis for a client with congestive heart failure with pulmonary edema is
- A. Pain
- B. Impaired gas exchange
- C. Cardiac output altered: decreased
- D. Fluid volume excess
Correct Answer: C
Rationale: Cardiac output altered: decreased. Increasing cardiac output is the primary goal of therapy, improving comfort and respiratory status.
The nurse is caring for a client with Grave's disease. Which finding would indicate a complication of the client's disease?
- A. Extreme fatigue
- B. Increased heart rate
- C. Shortness of breath
- D. Urinary frequency
Correct Answer: C
Rationale: Shortness of breath may indicate thyroid storm, a life-threatening complication of Grave's disease. Fatigue and increased heart rate are common symptoms, and urinary frequency is unrelated.
The nurse is caring for several 70 to 80 year-old clients on bed rest. What is the most important measure to prevent skin breakdown?
- A. Massage legs frequently
- B. Frequent turning
- C. Moisten skin with lotions
- D. Apply moist heat to reddened areas
Correct Answer: B
Rationale: Frequent turning. Frequent turning will prevent skin breakdown by relieving prolonged pressure on any one area.
A practical nurse (PN) is assigned to care for a newborn with a neural tube defect. Which dressing, if applied by the PN, would need no further intervention by the charge nurse?
- A. Telfa dressing with antibiotic ointment
- B. Moist sterile nonadherent dressing
- C. Dry sterile dressing that is occlusive
- D. Sterile occlusive pressure dressing
Correct Answer: B
Rationale: Before surgical closure, the sac is prevented from drying by the application of a sterile, moist, nonadherent dressing over the defect. Dressings are changed frequently to keep them moist.
The RN charge nurse hands the LPN/LVN a syringe filled with medication that the RN has just drawn and asks the LPN/LVN to administer this to a client. How should the LPN/LVN respond?
- A. Do as requested by the charge nurse
- B. Ask the charge nurse what the medication is and then administer it
- C. Ask the charge nurse what the medication is, check the order, and then administer it
- D. Refuse to administer the medication
Correct Answer: C
Rationale: Verifying the medication and checking the order ensures safe administration, adhering to medication safety protocols. Blind administration or refusal is unsafe or uncooperative.